COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00063835 


TiG/oi 


Hii 


College  of  ^pij^siciansi  anD  burgeons 


l^eference   Eibrarp 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofdiseasOOhirs 


A  TEXT-BOOK 


OF 


DISEASES  OF  WOMEN 


BY 

BARTON  COOKE  HIRST,  M.D. 

PROFESSOR    OF    OBSTETRICS    IN    THE    UNIVERSITY    OF    PENNSYLVANIA 
GYNECOIvOGIST    TO   THE   HOWARD,    THE  ORTHOPEDIC,    AND 
THE  PHILADELPHIA   HOSPITALS. 


Witb  655  miustrations 
man^  of  tbem  In  Colors 


PHILADELPHIA,  NEW  YORK,  LONDON 

W.  B.  SAUNDERS  &  COMPANY 
1903 


Copyright,  1905.  by  \V.  B.  Saunders  &  Company 


Registered  at  Stationers'  Hall,  London,  England 


PRESS   OF 

W.  B.  SAUNDERS   *   COMPANV 

PHILADELPHIA 


PREFACE 


This  book  on  the  diseases  of  women  has  been  prepared  as 
a  companion  volume  to  the  author's  "Text-book  of  Obstetrics," 
the  two  volumes  covering  the  whole  subject  of  gynecology.  It 
is  based  on  an  experience  of  twenty  years. 

The  illustrations  are  mainly  original,  for  the  most  part  from 
the  author's  service  in  the  Howard  Hospital,  of  Philadelphia. 
The  others  are  properly  credited.  The  micro-photographs  were 
prepared  by  Drs.  J.  C.  Hirst  and  McConnell.  The  section  on 
anesthetics  is  written  by  Dr.  B.  F.  Roller,  the  author's  anesthe- 
tizer. 

A  special  effort  has  been  made  to  describe  the  palliative 
treatment  of  diseases  of  women  and  such  curative  treatment  as 
can  be  carried  out  by  the  general  physician.  A  separate  section 
has  been  devoted  to  the  detailed  description  of  modern  operative 
technic. 

The  anatomical,  rather  than  the  pathological,  classification 
of  diseases  of  women  has  been  adopted,  as  in  the  author's  judg- 
ment the  most  logical  and  convenient. 

The  aim  of  the  work  is  to  present  a  concise  description  of 
all  the  diseases  peculiar  to  women,  with  especial  attention  to  diag- 
nosis and  treatment,  adapted  to  the  needs  of  the  medical  student, 
the  general  physician,  and  the  specialist. 

1S21  Spruce  Street, 
L^  September  i ,  igo^. 

r~ 
-±- 


CD 


ID 

> 

O 


CONTENTS 


PART  I.— THE  GYNECOLOGICAL  EXAMINATION;  LOCAL 


TREATMENT 


PART  II.— ANOMALIES  OF  DEVELOPMENT  IN   THE  GEN- 
ITAL TRACT     


PAGE 
17 


54 


Ovaries,  54 — Fallopian  Tubes,  54 — Uterus,  55 — Absence  or  Rudi- 
mentary Development  of  Uterus,  56 — Uterus  Unicornis,  57 — Uterus 
Didelphys,  59 — Uterus  Bicornis  Duplex,  61 — Uterus  Bicornis  Uni- 
collis,  61 — Uterus  Cordiformis,  61 — Uterus  Incudiformis,  62 — Uterus 
Septus,  Subseptus,  Partitus,  Semi-part-tus,  62 — Anomalies  of  Develop- 
ment in  Cervix,  63 — Atresia  of  Cervix,  63 — Arrested  Development  of 
the  Cervix,  64 — Hypertrophy  of  the  Cervix,  64 — Absence  of  Vagina,  65 
— Stenosis  of  the  Vagina,  70 — Vulva,  71 — Atresia  of  Vulva,  71 — Ar- 
rested Development  of  Urogenital  Sinus,  71 — Hyperplasia  and  Hy- 
pertrophy of  Vulvi,  72 — 111  Development  of  Vulva,  72 — Hypertrophy 
of  Chtoris,  72 — Anomalies  of  Hymen,  73 — Retention  of  Mucus  and 
Blood  within  the  Genital  Tract,  74 — The  Treatment  of  Retention 
within  the  Genital  Canal  of  Menstrual  Blood  and  Mucous  Discharge, 
78 — Hermaphroditism,  79 — Pseudohermaphroditism,  81. 

PART  III.— DISEASES     AND     INJURIES    OF    THE    VULVA; 

COCCYGODYNIA 89 

\^ulvitis,  92 — Gangrene,  99 — Pruritus  Vulvae,  100 — Kraurosis  Vul- 
vae, 103 — Cysts  and  Benign  Tumors  of  the  Labia,  Vestibule,  and 
Groins,  105 — Elephantiasis,  no — Varicocele,  no — Urethral  Caruncle, 
III — Hydrocele  of  Round  Ligament,  114 — Rodent  Ulcer,  114 — Tu- 
berculosis, 115 — Carcinoma,  116 — Sarcoma,  119 — Syphilis,  121  — 
Pudendal  Hernia,  122 — Diseases  of  the  Clitoris,  122 — Injuries  of  the 
Vulva,  123 — Coccygodynia,  125. 

PART  IV.— DISEASES  AND   INJURIES   OF    THE  VAGINA  .    .     131 

Vaginitis,  137 — Tuberculosis,  141 — Acquired  Stenosis  and  Atresia, 
141 — Injuries  of  the  Vagina  and  Pelvic  Floor,  145 — Treatment  of  a 
Cystocele,  163 — Treatment  of  Lacerations  of  Perineum  and  Pelvic 
Floor,  169 — Secondary  Perineorrhaphy,  169 — Secondary  Operation 
for  a  Median  Perineal  Tear,  170 — Secondary  Perineorrhaphy  for 
Complete  Tear  of  Perineum,  170 — Secondary  Perineorrhaphy  for 
Injury  to   the   Levator  Ani   Muscle,    Rectocele,    Overstretching   and 

II 


12  Contt^nts 

PAGE 

Subinvolution  of  \'agina,  176 — New-growths  of  \'agina,  185 — Cysts. 
1S5 — Fibromata,  1S7— Sarcoma,  188 — Carcinoma,  189 — Pointed 
Condylomata,  190 — Foreign  Bodies  in  \'agina,  u)2 — Fecal  Fistula 
in  \'agina,  192 — \'aginismus,  194. 

PART  v.— INJURIES  AND  DISEASES  OF  THE  CERVIX  .  198 
The  Treatment  of  a  Lacerated  Cervix,  206 — Cervicitis,  214 — Ero- 
sion, 214 — Endocervicitis,  216 — Ulceration,  218 — Tuberculosis,  218 — 
Acquired  Atresia,  220 — New-growths,  221 — Myomata,  221 — Car- 
cinoma, 225 — The  Roentgen  and  Finsen  Rays  for  Inoperable  and 
Recurrent  Cancers  of  Cervix,  261 — Hydatidiform  Sarcoma  of  Cervical 
Endometrium,  261. 

PART  VI.— DISPLACEMENTS     AND,    DISEASES     OF     THE 

UTERUS 264 

Mobility  and  Position  of  the  Uterus,  269 — Displacements,  270 — 
Retroflexion  and  Retroversion,  270 — .\nteposition,  Anteversion,  and 
.Anteflexion,  291 — Prolapse,  294 — Inversion,  306 — Metritis,  310 — 
Acute  Metritis,  310 — Chronic  Metritis,  311 — Subinvolution,  312 — 
Superinvolution  and  .\trophy,  313 — Injuries  of  the  Uterus,  314 — 
Foreign  Bodies,  315 — Hysteralgia,  315 — Neoplasms  of  Uterus,  316 — 
Fibromyoma,  316 — Treatment  of  Fibromyomata,  338 — Radical 
Treatment  of  Fibromyomata,  342 — Sarcoma,  353. 

PART  VIL— DISEASES  OF  THE  ENDOMETRIUM;  DISOR- 
DERS OF  MENSTRUATION;  STERILITY  ....  355 
Endometritis,  355 — Neoplasms,  364 — Adenocarcinoma,  364 — Sar- 
coma, 370 — Endothelioma,  372 — My.xomatous  Polyps,  373 — Men- 
struation, 373 — Menstrual  Molimina,  376 — Connection  between  Ovu- 
lation and  Menstruation,  379 — Amenorrhea,  381 — Vicarious  Men- 
struation, 384 — Menorrhagia,  384 — Dysmenorrhea,  385 — Membranous 
Dysmenorrhea,  388 — Sterility,  389. 

PART  VIII.— THE    FALLOPIAN  TUBES;    EXTRA-UTERINE 

PREGNANCY 392 

The  Fallopian  Tubes,  392— Diseases  of  the  Tubes,  394— Conges- 
tion, 394 — Displacements,  395— Inflammations,  395— Hydrosalpin.x, 
406 — Hematosalpinx,  409 — Tuberculosis,  409— Neoplasms,  412 — 
Symptoms  of  Tubal  Disease,  413— Treatment  of  Tubal  Inflamma- 
tion, 415— Extra-uterine  Pregnancy,  426— Clinical  History,  427— 
Changes  in  Uterus  and  Vagina,  427— Clinical  History  and  Pathology 
of  Tuljal  Pregnancy,  429— Clinical  History  of  Interstitial  Pregnancy, 
432— Clinical  History  of  Tubo-ovarian  Pregnancy,  432— Clinical 
History  of  Ovarian  Pregnancy,  432 — Clinical  History  of  .\lxlominal 
Pregnancy,  433 — Clinical  History  and  Pathology  of  Utero-abdominal 
Pregnancy,  433 — Terminations  of  Extra-uterine  Pregnancy,  433 — 
Symptoms  of  Extra-uterine  Pregnancy,  437— Symptoms  of  Interstitial 
Pregnancy,  439 — Symptoms  of  Abdominal  Pregnancy,  439— Diagnosis 


Contents  13 


PAGE 


of  Extra-Uterine  Pregnancy,  439 — Prognosis  of  Extra -uterine  Preg- 
nanc)',  440 — Treatment  of  Extra-uterine  Pregnancy,  440 — Pregnancy 
in  One  Horn  of  a  Uterus  Bicornis  or  Unicornis,  444. 

PART  IX.— DISEASES   OF  THE   OVARIES 445 

•  Displacements,  448 — Prolapse,  449 — Ovarian  Hernia  or  Ovariocele, 
451 — Ovarian  Congestion,  453 — Ovarian  Hemorrhage,  456 — Atrophy, 
458 — Inflammations,  459 — Tuberculosis,  460 — Actinomycosis,  461 — 
Chronic  Oophoritis,  461 — Neoplasms,  463 — Simple  Serous  Cysts,  464 
— Pseudomucin  Cystadenomata,  465 — Serous  Cystadenomata,  471 — ■ 
Papillomatous  Growths  in  Ovarian  Cysts,  472 — Ovulogenous  Ovarian 
Tumors,  Dermoids  and  Teratomata,  474 — Teratoma,  479 — Carci- 
noma, 479 — Stromatogenous  Neoplasms,  481 — Fibromata,  481 — Sar- 
comata and  Endotheliomata,  482 — Parovarian  Cysts,  484 — Clinical 
History  of  Ovarian  Tumors,  486 — Twisted  Pedicle,  487 — Rupture, 
488 — Inflammation  and  Suppuration,  489 — Symptoms  and  Diagnosis 
of  Ovarian  Tumors,  490 — Treatment  of  Ovarian  Tumors,  495 — 
Foreign  Bodies,  504 — Echinococcus  Cysts,  504 — Implantation  and 
Transplantation,  504. 

PART  X.— DISEASES  OF  THE   PELVIC   CONNECTIVE  TIS- 
SUE AND   OF  THE  PERITONEUM      506 

Inflammation,  508 — Injuries,  511 — Neoplasms,  514 — Fibromyomata, 
514 — Echinococcus  Cysts,  516 — Actinomycosis,  517 — Varices  or  Vari- 
cocele of  Broad  Ligament,  517 — Phleboliths,  518 — Pelvic  Peritonitis, 
519 — Pelvic  Hematocele,  520. 

PART    XL— DISEASES  OF  THE  URINARY  TRACT 522 

Examination  of  the  Female  Urinary  Tract,  527 — Cystoscopy,  527 — 
Congenital  Malformations  of  the  Bladder,  535 — Displacements  of 
the  Bladder,  535 — Diseases  of  the  Bladder,  535 — Cystitis,  535 — Con- 
traction of  the  Bladder,  539 — Neoplasms  of  the  Bladder,  540 — 
Vesical  Calculus,  541 — Urinary  Fistula,  541 — The  Treatment  of  Ure- 
teral Fistula  and  of  Surgical  Injuries  of  the  Ureters,  551 — Malforma- 
tions and  Diseases  of  the  Urethra,  556 — Total  Defect  of  the  Urethra, 
556 — Partial  Defect  of  the  Urethra,  556 — Atresia  Urethrae,  5.56 — 
Urethralgia,  557 — Urethritis,  557 — Granular  Erosion  of  Urethra,  558 
— Stricture,  558 — Vesico-urethral  Fissure,  559 — Neoplasms  of  Urethra, 
559 — Dilatation  or  Dilatability  of  the  Urethra,  560 — Displacements  of 
Urethra,  562 — Prolapse  of  Urethral  Mucous  Membrane,  563 — Foreign 
Bodies  in  Urethra,  565 — Urethral  Fistula,  565 — Tuberculosis  of 
Urethra,  565 — Floating  Kidney,  566. 

PART  XII.— THE    DETAILED   TECHNIC   OF  GYNECIC  SUR- 
GERY      577 

The  Operating.  Room,  577 — Operating  Table,  585 — Instruments 
and  their  Preparation,  586 — Special  Instruments,  589 — Dressings 
and   the    Packing   of   the   Autoclaves,    591 — Sutures   and   Ligatures, 


14  Contents 

r.M.K 
5^)3 — The  Preliminary  Treatment  and  K.xamination  of  the  Patient, 
596 — Hand  and  Skin  Cleansing,  508— Preparation  of  Patient  for  an 
Abdominal  Section,  600 — Preparation  of  Patient  for  a  Plastic  Opera- 
tion, 602 — Preparation  of  Surgeon;  Clothes,  Gowns,  and  Gloves, 
602 — Anesthesia  and  Anesthetics,  603— The  Technic  of  an  Abdominal 
Section,  611 — The  Technic  of  a  Vaginal  Section,  640 — The  Technic 
of  a  Plastic  Operation,  642— Technic  of  Dilatation  of  the  Cer\ix 
and  Curettage  of  the  Uterine  Cavity,  645— The  After-treatment  of 
an  Abdominal  Section,  646 — The  Treatment  of  Shock  during  and 
after  an  Abdominal  Section,  654 — Sef|uels  of  Abdominal  Surgery, 
655 — The   After-treatment  of  a   Plastic   ()])eration,    660. 


INDEX 665 


A  TEXT-BOOK 

OF 

DISEASES    OF   WOMEN 

HIRST 


PART  I. 

THE  GYNECOLOGICAL  EXAMINATION;  LOCAL 
TREATMENT, 

In  eliciting  the  symptoms  of  a  disease  peculiar  to  women,  the 
subjective  and  the  objective  s}'mptoms  should  be  investigated. 
The  former  are  experienced  by  the  woman  and  must  be  commu- 
nicated by  her;  the  latter  are  determined  by  the  senses  of  the 
examining  physician,  usually  by  inspection  and  palpation. 

The  subjective  symptoms  are  obtained  by  questioning  the 
patient.  Obviously,  too  much  importance  must  not  be  attached 
to  them.  The  woman  ma}-  not  have  accurately  observed  her 
condition ;  she  may  misinterpret  what  she  feels ;  she  may  be 
neurasthenic  or  hysterical,  and  therefore  may  exaggerate  or  simu- 
late symptoms.  1  She  may  purposely  give  a  false  history,  or  she 
may  be  incapable  of  making  a  statement  if  she  is  drunk, 
delirious,  unconscious,  or  insane.  The  subjective  symptoms, 
however,  possess  a  certain  value,  and  should  always  be  ascer- 
tained if  possible.  Time  is  saved  and  errors  of  omission  are 
avoided  by  a  routine  series  of  questions  in  regular  order.  Thus, 
the  patient's  age  and  social  state;  any  important  diseases  or  acci- 
dents in  her  past  life;  a  hereditary  tendency  to  cancer  or  tuber- 
culosis ;  the  number  of  children  or  miscarriages,  if  any ;  difficulty 
in  the  labors  or  afterward. 

Menstruation. — The  age  at  which  it  first  appeared ;  the  inter- 
vals between  the  periods;  the  duration  of  the  flow;  its  character 
and  quantity.  Are  clots  passed?  Has  the  discharge  a  foul 
odor?  Is  there  intermenstrual  bleeding?  Has  the  menopause 
occurred  ?  If  so,  when  ;  and  has  there  been  any  bloody  dis- 
charge since  ? 

Leukorrhea. — If  there  is  a  mucopurulent  discharge,  what  are 
its  exact  character  and  quantity?  Is  it  constant?  Has  it  a  foul 
odor  ?      Does  it  appear  midway  between  the  periods  ? 

Pain  is  next  inquired  for  ;  its  situation  and  character ;  whether 
it   is  influenced  by  menstruation;  if  it  is   worse  before,  during. 

^  One  of  my  patients  put  the  fur  of  a  cat  in  her  urine;  another  wrapped  tresses  of 
her  own  hair  around  the  fecal  masses  she  defecated,  suggesting  the  communication 
of  a  dermoid  cyst  with  the  bladder  and  bowel. 

2  17 


1 8  The  Gynecological  Examination 

or  after  the  flow.  Is  it  affected  by  a  sudden  jolt  or  jar,  or  by 
coitus?  Does  it  occur  midway  between  the  periods  ("  Mittel- 
schmerz  ")  ? 

Backache  should  be  asked  about  separately:  Is  it  worse  on 
exertion  or  on  first  arising  in  the  morning?  Is  it  affected  by 
mental  effort  ?  Is  its  situation  the  small  of  the  back  or  the  very- 
end  of  the  spine  ? 

When  the  patient  stands  erect,  is  there  a  sense  of  prolapse,  or 
lack  of  support?      Is  there  an  actual  protrusion  from  the  vagina? 

Is  there  any  peculiarity  of  defecation  or  urination? 


Fig.   I. — Characteristic  gesture  of  tubo-ovarian  pain. 

Finally,  the  general  health  should  be  investigated  :  loss  of 
weight,  pallor,  feeble  circulation,  headache,  localized  pains 
remote  from  the  sexual  organs;  sleeplessness  and  nervousness 
must  be  asked  about.  The  answers  to  all  these  questions  may 
suggest  further  inquiries.  It  is  often  advisable  to  inquire  into 
the  sexual  relations  of  married  women,  more  particularly  as  to 
the  means  which  may  be  taken  to  prevent  conception. 

Conclusions  of  a  certain  value  may  be  drawn  from  the 
answers  to  these  questions.  If  a  woman  has  pain  above 
Poupart's  ligaments,  worse  before  or  after  men.struation,  and 
somewhat  relieved  during  the    flow,  she  probably  has  a  tubo- 


Objective  Symptoms  19 

ovarian  inflammation,  which  is  usually  more  acutely  felt  on  the  left 
side,  even  though  both  sides  are  equally  affected.  If  there  is 
inflammatory  disease  of  the  uterine  appendages,  there  is  usually 
an  acute  pain  in  consequence  of  a  jolt  or  jar,  as  in  a  sneeze,  and 
in  coitus.  In  describing  the  situation  of  this  pain  the  patient 
usually  makes  a  characteristic  gesture. 

If  there  is  backache,  worse  in  the  morning  and  not  aggra- 
vated by  exertion,  there  is  probably  a  strong  neurasthenic 
element  in  the  case,  or  there  may  be  rheumatism  of  the  lumbar 
muscles.  Backache  only  appearing  on  or  much  aggravated  by 
exertion  in  the  erect  posture  suggests  retroversion  of  the  uterus 
or  injury  of  the  pelvic  floor.  Pain  in  the  end  of  the  spine  should 
arouse  a  suspicion  of  neurasthenia  or  hysteria,  for  this  is  a  favorite 
seat  of  imaginary  pain  ;  but  it  may  indicate  coccygodynia  in  con- 
sequence of  an  injury  to  the  bone  or  its  joints. 

It  is  unwise,  however,  to  form  too  strong  a  preconceived 
opinion  from  the  subjective  symptoms  alone.  Even  an  experi- 
enced specialist,  on  making  a  physical  examination,  may  oc- 
casionally imagine  he  finds  the  signs  of  a  condition  which  really 
does  not  exist,  if  his  mind  has  been  too  firmly  preoccupied  by 
the  thought  of  some  disease  suggested  by  the  patient's  state- 
ments. 

Objective  Symptoms. — While  the  patient  is  entering  the 
office,  giving  her  history,  and  replying  to  the  physician's  questions, 
information  of  some  value  is  obtained  by  an  observation  of  her 
appearance  and  behavior.  A  slow,  cautious  gait,  with  the  body 
bent  forward,  the  hand  perhaps  resting  on  the  abdomen,  an  evi- 
dent care  to  avoid  a  jolt  or  jar,  and  an  apprehensive  expression 
on  the  face  are  indicative  of  pelvic  peritonitis  or  peritoneal  irrita- 
tion. The  cachexia  of  cancer,  the  intense  pallor  of  anemia  from 
metrorrhagia,  the  greenish-yellow  skin  of  chlorosis,  the  sallow 
complexion  of  sepsis,  the  evidence  of  malnutrition  in  the  fades 
ovaviana,  the  shifty  glance  and  twitching  eyelids  of  hysteria  are 
all  suggestive  and  should  be  noted.  There  are  lines  of  care  upon 
the  face  and  a  prematurely  aged  look  in  many  a  case  of  uterine 
displacement.  The  cosmetic  effect  of  a  uterine  suspension,  for 
example,  is  often  very  striking.  The  most  valuable  objective 
symptoms,  however,  are  appreciable  by  the  sense  of  touch. 

Palpation  of  the  pelvic  organs  in  women  is  most  often 
practised  by  a  digital  examination  of  the  vagina,  assisted  by 
counterpressure  upon  the  lower  abdomen  {combined  vaginal  and 
abdondnal  examination  ;  bimanual  exannnatioii).  The  patient  is 
usually  placed  upon  her  back,  preferably  on  a  specially  con- 
structed table,  with  the  buttocks  projecting  slightly  beyond  its 
edge,  the  trunk  flexed  just  above  the  sacrum,  the  pelvis  slightly 


20 


The  Gynecological  Examination 


elevated,  the  thighs  well  flexed  upon  the  abdomen,  the  legs  upon 
the  thighs,  the  knees  widely  separated,  and  the  feet  supported 
upon  stirrups  not  too  far  apart.  This  posture  relaxes  the  ab- 
dominal muscles  and  removes  the  intestines  from  the  pelvic  cav- 


Fig.  2. — Examining  table  for  office  practice. 

ity.  The  lower  bowel  and  the  bladder  should  be  empty.  Corsets 
should  be  removed  and  the  clothing  loosened  around  the  waist. 
A  sheet  is  so  arranged  about  the  patient  that  her  limbs  and  body 
are  covered  and  her  underclothing  is  concealed  from  view,  but 
ready  access   to  the    genitalia  by  touch   and  sight  is  permitted. 


Fig.    3. — Office  sterilizer  for  instruments.     The  water  is    kept    boiling    during    the 

office  hour. 


If  a  suitable  table  is  not  at  hand,  the  patient  may  be  arranged 
across  a  bed  with  the  feet  supported  on  chairs. 

The  physician  cleanses  his  left  hand  and  anoints  the  first  two 
fingers  with  an   unguent.      The  best  for  the  purpose  is  composed 


Palpation 


21 


Fig.  4. — Instruments  laid  out  for  routine  office  work:  A  Sims',  skeleton, 
Goodell,  and  Collin's  speculum  ;  a  repositor,  uterine  sound,  Emmet's  curetment 
forceps,  Thomas'  applicator,  and  two  dressing  forceps  of  different  lengths.  The 
instruments  have  been  boiled,  are  laid  on  a  clean  towel  upon  a  glass-top  table  and 
covered  with  another  towel  so  that  they  shall  not  alarm  the  patient.  If  the  temper- 
ature of  the  examining  room  is  over  70°,  as  it  should  be,  the  instruments  need  not 
be  warmed  before  introduction  into  the  vagina.  If  the  room  is  cold,  they  should  be 
momentarily  dipped  in  the  water  boiling  in  the  sterilizer.  Immediately  after  use 
they  are  washed,  boiled  again,  dried,  and  laid  out  as  before. 


Fi£ 


5. — Patient  in  the  dorsal  gynecological  position,  with  sheet  draped  to  protect 
the  underclothing,  but  exposing  the  genitalia. 


22 


The  Gynecoloi^ical   Examination 


of  glycerin  and  Iceland  nio.ss,  scented  with  oil  of  roses.  ^  If 
there  is  leukorrhea,  a  foul  discharge,  a  suspicion  of  gonorrhea  or 
syphilis,  a  short  rubber  glove  without  a  gauntlet  should  be  worn. 
The  forefinger  approaches  the  vulvar  orifice  in  such  a  manner  that 
it  first  comes  in  contact  with  the  posterior  commissure,  which 
is  pushed  backward  toward  the  sacrum  as  the  finger  enters 
the  vagina.  Unless  care  is  exercised  about  this  point,  the  ves- 
tibule and  the  region  around  the  clitoris,  the  most  sensitive  por- 
tions of  the  external  genitalia,  may  be  fir.st  touched  before  the 
vaginal  orifice  is  found,  causing  the  patient  unnecessary  pain.     In 

inserting  the  finger  into  the  vagina 
it  should  be  remembered  that  the 
canal  runs  backward  toward  the 
sacrum,  and  not  upward  in  the 
axis  of  the  trunk.  As  soon  as 
the  cervix  is  located,  pressure  is 
made  upon  the  lower  abdomen 
with  the  fingers  of  the  free  hand 
to  locate  the  fundus  uteri  and  to 
press  it  downward  toward  the 
finger  in  the  vagina,  until  the 
corpus  uteri  is  caught  between 
the  fingers  of  the  hand  above  and 
the  finger  in  the  vagina,  which 
has  been  shifted  from  the  cervi.x, 
against  which  its  palmar  surface 
first  rested,  to  the  anterior  vagi- 
nal \ault.  In  this  way  the  posi- 
tion, size,  shape,  consistency,  and 
mobility  of  the  uterus  are  deter- 
mined. To  palpate  the  append- 
ages on  the  left  side,  the  middle 
finger  of  the  left  hand  is  inserted 
alongside  the  forefinger,  because 
thus  a  half  inch  in  length  is 
gained,  the  third  and  little  fingers 
are  flexed  in  the  palm  of  the  hand,  the  thumb  is  extended,  and  the 
hand  is  scmi-supinated.  The  extended  fingers  of  the  right  hand 
are  placed  with  their  tips  in  a  line  above  Poupart's  ligament,  and 
perpendicular  to  it,  well  outuard  toward  the  anterior  spine  of  the 
ilium,  with  the  palmar  surfaces  of  the  fingers  directed  downward 
and   inward.      This   hand  is  semi-pronated.      Pressure  is  exerted 

'  A  glycerin  jelly,  a  jeliy  of  cucumbers  and  liydrastis,  a  thick  mucilage  of  quince 
seeds,  or  plain  glycerin  are  all  preferable  to  ])i.-trolatum,  which  stains  linen  and  cloth- 
ing. 


Fig.    6. — Short     rubber     glove    fi 
gynecological  examinations. 


Fig.  7. — Introduction  of  the  forefinger  in  a  vaginal  examination,  by  retracting  the 

perineum 


Fig.  S. — Bimanual  examination  of  the  uterus.      Introduction  of  the  fingers  of  the  left 

hand,  which  is  then  supinated. 

23 


24 


The  Gynecolosfical  Examination 


by  the  external  hand  downward  and  inward,  until  the  ovary  is 
caught  between  the  external  and  internal  fingers,  and  the  tube 
can  be  rolled  between  them.  To  examine  the  appendages  on  the 
right  side,  the  first  two  fingers  of  the  right  hand  must  be  inserted 
in  the  vagina  and  the  fingers  of  the  left  hand  are  used  externally. 
It  is  sometimes  useful  to  pull  the  uterus  down  by  a  single  or 
double  tenaculum  in  order  to  palpate  it  and  its  appendages,  but 
in  the  vast  majority  of  cases  more  can  be  accomplished  by  pres- 
sure from   above   than   by  traction   from   below,  and   every  one 


Fig.  9. — Bimanual  examination  of  the  left  tube  and  ovary. 


should  aim  to  dispense  with  the  tenaculum  in  a  combined  exam- 
ination, for  it  causes  unnecessary  traumatism  and  may  be  respon- 
sible for  infection. 

As  the  woman  lies  upon  her  back  it  is  usually  advisable  to 
follow  the  vaginal  by  a  rectal  examination.  Tlic  forefinger,  pro- 
tected by  a  thin  rubber  finger-cot,  is  well  anointed  and  is  passed 
into  the  rectum  its  full  length.  Pressure  is  made  above  the  pubis 
by  the  free  hand,  as  in  a  combined  vaginal  and  abdominal  exam- 
ination.    To  palpate  the  uterine  appendages,  the  left  forefinger  is 


Examination   in  the  Erect  Posture  25 

used  for  the  left  side  of  the  pelvis,  the  right  forefinger  for  the 
right  side,  counterpressure  being  made  in  the  iliac  regions,  as 
already  described.  Very  rarely  it  may  be  desirable  to  make  a 
combined  rectal,  vaginal,  and  abdominal  examination,  which  is 
accomplished  by  inserting  the  forefinger  of  the  left  hand  in  the 
rectum,  the  thumb  in  the  vagina,  and  by  making  pressure  with 
the  free  hand  on  the  lower  abdomen.  The  cervix  and  lower 
uterine  segment  can  then  be  grasped  between  the  thumb  and  the 
forefinger. 

It  is  sometimes  necessary  to  examine  a  patient  in  the  erect 


Fig.   10. — Examination  in  the  erect  posture. 

posture — for  example,  to  determine  the  degree  of  prolapsus  uteri. 
For  this  purpose  the  woman's  skirts  are  raised  above  her  waist 
and  are  pinned  behind  or  are  removed.  A  sheet  is  pinned 
around  her  waist,  draped  so  that  it  falls  to  the  ground,  and  the 
two  edges  overlap  in  front  six  to  twelve  inches.  The  patient 
stands  with  her  legs  apart.  The  examiner  kneels  on  his  right 
knee,  facing  the  patient;  the  left  hand  is  inserted  under  the  sheet, 
through  the  opening  in  the  front,  and  the  forefinger  is  passed 


26 


The  Gynecological   Examination 


into  the  vagina,  the  physician's  elbow  being  supported  by  his 
knee. 

Palpation  of  the  abdomen  should  constitute  a  part  of  every 
routine  examination.  Tumors  or  other  abnormalities  may  thus 
be  detected  which  might  not  be  appreciable  in  a  vaginal  or  a 
combined  examination.  Abnormal  mobilitx'  of  the  kidneys  is 
overlooked  in  a  considerable  proportion  of  women  if  abdominal 
palpation  is  omitted. 

The  patient  is  prepared  for  abdominal  palpation  by  removing 
the  corsets,  loosening  the  skirts  and  the  underclothing  about  the 
waist,  and  exposing  the  skin  from  the  sternum  to  the  pubis. 
The  woman  lies  flat  upon  her  back,  with  the  knees  slightly  eleva- 
ted and  the  feet  supported.     The  examiner  stands  beside  her  and 


Fig.  II. — Abdominal  palpation. 


with  outstretched  hands  makes  pressure  at  first  lightly,  then  more 
deeply  from  the  flanks  toward  the  median  line,  and  from  top  to 
bottom  of  the  abdomen.  Deep  pressure  with  the  finger-tips  may 
be  needed  in  certain  areas.  The  contour  of  an  abdominal  tumor 
may  be  determined  by  grasping  it  as  one  grasps  the  fundus  uteri 
in  Crede's  method  of  expressing  the  placenta.  By  approximat- 
ing the  finger-tips  from  without  inward  and  at  the  same  time  mak- 
ing deep  pressure  the  abdominal  walls  are  lifted  away  from  the 
abdominal  contents.  In  this  way  mere  obesity  is  differentiated 
from  an  intra-abdominal  tumor. 

To  palpate  the  kidneys  the  patient  should  be  made  to  sit  bolt 
upright,  upon  the  examining  table,  with  the  abdomen  freely  ex- 


Palpation  of  the  Abdomen 


27 


posed,  the  back  and  head  supported,  the  arms  hanging  loosely 
by  her  side,  and  all  the  muscles  as  relaxed  as  possible.  The 
examiner,  standing  beside  her,  places  one  hand  on  the  lumbar 
region  and  slips  the  fingers  of  the  other  under  the  floating  ribs  in 
front.  In  this  manner  the  kidney  is  caught  between  the  two 
hands  and  its  mobilit\'  can  easily  be  tested.  Another  posture 
frequently  used  for  palpation  of  the  kidneys  is  assumed  by  the 
patient,  seated,  leaning  forward,  with  the  upper  portion  of  her 
trunk  supported  by  a  nurse.  The  examination  of  the  kidney  in 
the  erect  posture  with  flexed  trunk,  in  the  knee-elbow  and  in 
the  Sims'  position  is  described  under  the  head  of  Floating  Kidney. 


Fig.  12. — Testing  the  thickness  of  the  abdominal  walls. 


A  satisfactory  pelvic  and  abdominal  palpation  ma}-  be  impos- 
sible without  anesthesia.  In  an  unmarried  woman  anesthet- 
ization should  always  be  insisted  upon  unless  she  has  been 
examined  and  perhaps  treated  before.  If  the  patient  is  a  young 
girl,  it  is  better  to  keep  her  in  ignorance  of  what  is  to  be  done, 
and,  if  possible,  the  vaginal  should  be  replaced  by  a  rectal  exam- 
ination. If  there  is  uncontrollable  rigidity  of  the  abdominal  and 
pelvic  muscles,  hypersensitiveness  of  the  genital  region,  or  if  for 
any  cause  the  examination  is  difficult  and  the  result  is  not  per- 
fectly clear,  a  physician  should  refuse  to  give  his  opinion  of  the 
case  until  an  examination  under  anesthesia  is  permitted.  The 
best  anesthetic  for  the  purpose  is  chloroform.      It  secures  perfect 


28 


The  Gynecological  Examination 


relaxation  quickly,  and  does  not,  as  a  rule,  nauseate  the  patient, 
used  in  the  small  quantities  and  for  the  short  time  required. 
Ether  is  too  slow  in  its  action  and  causes  too  much  nausea. 
Nitrous  oxid  gRv,  does  not  relax  tlie  muscles  enough.  Ethyl- 
bromid  and  chlorid  are  too  dancrerous. 


Pig.  1^. — Palpation  of  the  left  kidney,   as  the  patient,  sitting  erect,   leans  forward 

against  the  nurse. 


Inspection  of  the  Pelvic  Organs  and  of  the  Abdomen. — As   the 

patient  is  arranged  for  a  digital  examination  of  the  vagina,  her 
vulva  is  e.xpo.scd  to  view  and  should  be  inspected  before  the 
physician  in.serts  his  finger.  The  entrance  of  the  vagina  and  the 
vestibule  are  exposed  by  separating  the  labia  majora  with  the 
thumbs  or  forefingers.  The  vagina  itself,  its  vault,  and  the  cervix 
uteri  are  exposed  by  the  use  of  a  bivalve  or  a  duck-bill  (Sims') 
speculum.  The  former  is  the  more  useful  instrument  of  the  two. 
The  Collin's,  Goodell's,  and  the  skeleton  are  the  most  convenient 


Introduction  of  Bivalve  Speculum 


29 


models.      Two  sizes  must  be  provided,  for  muciparous  and  nuU- 
iparous  women. 

To  introduce  a  bivalve  speculum,  the  instrument  is  grasped 
in  the  fingers  of  the  right  hand,  near  the  junction  of  the  blades, 
which  are  held  close  together.  The  tips  of  the  blades  are 
dipped  in  a  jar  of  unguent.  The  forefinger  of  the  left  hand 
is  inserted  in  the  vagina  to  locate  the  cervix  and  to  indicate  the 
direction  of  the  vaginal  canal.      As  the  finger  is  withdrawn  the 


Fig.  14. — Exposure  of  the  clitoris,  vestibule,  vaginal  introitus,  and  fossa  navicularis. 


right  labium  majus  is  pushed  to  one  side  and  the  vaginal  entrance 
is  thus  made  to  gape.  The  speculum  is  now  inserted  with  the 
long  axis  of  the  blades  corresponding  with  the  direction  of  the 
vagina — namely,  backward  toward  the  sacrum,  rather  than  upward 
in  the  line  of  the  trunk;  the  tips  are  turned  so  that  their  long  axis 
corresponds  with  the  long  axis  of  the  vulvar  orifice,  and  the  screw 
is  directed  downward.  As  the  instrument  is  passed  into  the 
vagina  it  is  turned  on  its  long  axis  so  that  the  blades  rest 
against  the   anterior  and  posterior  vaginal  walls,  and  the  screw 


so  The  Gynecolog-Ical  Examination 

which  separates  them  is  on  tlie  left-hand  side  of  the  woman's 
pelvis,  where  the  examiner's  right  hand  may  easily  manipulate  it. 
If  the  proper  direction  of  the  speculum  is  maintained  while  it  is 
being  inserted,  the  cervix  is  exposed  as  the  blades  are  separated ; 


Fig.  15.- — Collin's  speculum. 


Fig.  16. — GoodeU's  speculum. 


Skeleton  bivalve  speculum. 


but  the  mistake  is  commonly  made  of  not  pointing  the  instru- 
ment far  enough  backward,  so  that  wiien  it  is  opened  the 
anterior  vaginal  vault  is  exposed  and  the  cervix  is  hidden 
beneath  the  po.stcrior  blade.      Shoukl  this  be  the  case,  the  blades. 


The  Sims'   Speculum 


31 


are  allowed  to  collapse,  the  instrument  is  withdrawn  a  little 
and  then  pushed  far  backward  toward  the  sacrum  until  the  cervix 
comes  into  view  as  the  blades  are  separated.  If  the  vagina  is 
long  and  its  walls  are  relaxed,  a  single  tenaculum  may  be 
required  to  catch  the  cervix,  by  passing  it  into  the  external  os 
with  the  hook  directed  upward  and  catching  hold  of  the  anterior 
lip.  A  bivalve  speculum  properly  introduced  and  widely 
enough  opened  is  usually  self-retaining,  leaving  the  operator's 
hands  free  for  whatever  manipulations  may  be  required. 

If  a  Sims'  speculum  is  used  in  the  dorsal  position,  the  ante- 


^"1    -4 

^^m  '          "'^MPHW^ 

Ik.                     ^       * 

IHfcipr 

^^^^^^^BBJiSSiiwMMypy '  '^'-'^y^^^^^^ 

i 

Fig.  18. — Introduction  of  the  bivalve  speculum. 


rior  vaginal  wall  pi"olapses  into  the  vulvar  orifice  and  obscures 
the  view  of  the  deeper  portion  of  the  canal,  so  that  a  re- 
tractor is  required  to  push  it  upward  out  of  the  way.  Special 
instruments  are  devised  for  the  purpose,  but  the  ring  handle  of 
one  blade  of  a  two-bladed  instrument,  such  as  a  Pean's  forceps, 
answers  the  purpose  perfectly.  Edebohls  has  devised  a  self- 
retaining  duck-bill  speculum  with  an  attachment  to  catch  dis- 
charges and  irrigating  fluids,  which  is  often  very  useful  in  the 
dorsal  decubitus. 

The  best  results  with  the  Sims'  speculum  are  obtained,  how- 


32 


The  Gynecological  Examination 


ever,  in  the  Sims'  or  semi-prone  lateral  position  and  in  the  knee- 
chest  posture.  In  the  Sims'  position  the  patient  is  placed  upon 
her  side,  usually  the  left,  with  the  under  arm  behind  her  back, 
the  trunk  in  a   semi-prone  position,  the  thighs  well  flexed  upon 


Fig.  19. — Sims'  specula.      Detachable  blades  of  varying  sizes  and  liandle. 


Fig.  20. — Sims'  speculum.      Blades  of  two  sizes  in  one  instrument. 


Fig.  21. — Nott's  vaginal  depressor. 


the  abdomen,  and  the  legs  upon  the  thighs,  the  upper  leg  and 
thigh  being  soniewiiat  more  strongly  flexed  than  the  lower.  The 
advantages  of  the  Sims'  position  are  increased  if  the  table  on 
which  the  woman  lies  is  tilted  .so  that  the  abdomen  is  made  still 
more  dependent.      The   knce-che.st  postin-e  is  assumed  by  resting 


The  Knee-chest  Posture 


33 


upon  the  knees  and  chest,  the  face  turned  aside  so  that  one  cheek 
rests  upon  a  flat  pillow  and  the  arms  so  disposed  that  the  patient 
can  not  yield  to  her  instinctive  impulse  to  rest  upon  the  elbows. 


Fig.  22. — Sims'  position. 


Fig.  23. — Sims'  position.     Patient  draped  with  sheet,  arranged  so  as  not  to  interfere 
with  the  examination  or  manipulations. 


The  thighs  should  be  perpendicular  to  the  surface  of  the  table, 
and  the  back  should  present  a  straight  line  or  a  somewhat  con- 
cave curve  at  an  angle  of  90  degrees. 
3 


34 


The  Gynecological  Examination 


Fig.  24. — Knee-chest  posture.      Thighs  perpendicular  to  the  table  ;  back  at  an  angle 

of  90  degrees. 


M^ 

^H 

^^1 

/-'^^l 
.^-^^--  .     •■ 

"   W/'^^-'"^*^ 

1                    ^^^^H 

F'g-    25. — Knee-chest   posture.       Sheet    draped   around   patient.       Posture    faulty. 
Thighs  not  perpendicular. 


Introduction  of  the  Sims'   Speculum 


Fig.  26. — Introduction  of  a  Sims'  speculum. 


Fig.  27. — Sims'  speculum,  introduced  and  held  by  a  nurse. 


36 


The  Gynecological  Examination 


To  introduce  the  Sims'  speculum  in  the  Sims'  position,  the 
convex  surface  of  the  blade  is  well  anointed,  the  handle  is  grasped 
in  the  full  hand,  the  vaginal  orifice  at  its  posterior  commissure  is 
opened  by  raising  the  upper  buttock,  and  the  blade  of  the  instru- 
ment is  inserted  with  the  long  axis  of  its  tip  in  coincidence  with 
the  long  axis  of  the  vulv^ar  orifice.  As  it  is  inserted  the  blade  is 
turned  until  the  handle  points  directly  backward  toward  the 
sacrum.  The  handle  must  also  be  inclined  somewhat  away  from 
the  perineum,  else  the  blade  will  slip  out.  An  assistant  holds 
the  handle  firmly  in  the  full  hand  and  makes  considerable  traction 
backward  and  outward.  A  retractor  may  be  needed  for  the 
anterior  wall,  and  a  tenaculum  may  be  required  to  bring  the  cer- 
vix into  view,  although  usually  the  vagina  is  well  distended  with 
air    and    every   part    of  the    canal    is   plainly   displayed,   except 

that  covered  by  the  blade  of  the 
instrument.  To  insert  the  Sims' 
speculum  in  the  knee-chest  pos- 
ture, the  same  manoeuvers  are 
practised,  except  that  the  vulvar 
orifice  is  opened  for  the  insertion 
of  the  blade  by  one  or  two 
fingers. 

There  are  several  models  of 
self-retaining    duck-bill    specula, 
permitting  one  to  dispense  with 
an     assistant  ;      but     they     are 
bulky     and     expensive     instru- 
ments,   scarcely  ever    employed 
by  any  one  who  can  command 
the  services  of  a  nurse  to  assist 
in   gynecological  examinations.  ^ 
Edebohls'  instrument  is  sometimes  a  convenience  in  the  dorsal 
decubitus,  to  receive  discharges  or  fluids  in  a  tin  cup  attached  to 
its  lower  end. 

The  cylindrical  speculum  is  very  rarely  employed.  It  is 
only  useful  for  the  purpose  of  bathing  the  cervix  in  medicinal 
solutions,  which  are  poured  into  it  after  its  insertion  until  the 
cervix  is  submerged.      As  the  speculum  is  withdrawn  the  solution 


Fig.  28. — Edebohls'  self-retaining 
speculum. 


'A  word  of  caution  in  this  connection  is  necessary  to  the  inexperienced.  At 
least  four  or  five  of  the  author's  personal  friends  in  recent  years  have  been  falsely 
accused  of  attempts  at  assault  during  office  examinations  of  female  patients.  The 
physician,  therefore,  who  expects  to  treat  diseases  of  women  should  make  any 
sacrifice  to  secure  the  services  of  an  office  nurse,  who  is  not  only  an  invaluable  aid  in 
the  preparation  of  the  patient  for  examination  and  in  the  various  methods  of  examina- 
tion and  treatment,  but  is  also  a  safeguard  against  a  serious  risk  of  attempts  at 
blackmail. 


Inspection  of  the  Abdomen 


11 


bathes  the  successive  layers  of  the  vaginal  wall  which  prolapse 
into  its  opening. 

To  introduce  the  cylindrical  speculum  the  longer  end  is 
placed  posteriorly.  A  rotary  motion  facihtates  its  introduction. 
It  is  pushed  backward  and  upward  until  the  cervix  is  engaged  in 
its  distal  end.  Cylindrical  specula  are  made  of  metal,  glass,  hard 
rubber,  and  wood.  The  last-named  material  is  designed  for  the 
application  of  the  actual  cautery  to  the  cervix.  Ferguson's 
speculum  has  a  mirror  coating  on  its  internal  surface. 

The  inspection  of  the  abdomen  may  fiirnisJi  informatioii  of  the 
greatest  valne.  Flaccidity  of  the  walls,  indicating  enteroptosis 
and  gastroptosis,  when  the  individual  stands  erect,  tympany, 
obesity,  pregnancy,  ascites,  hernia,  the  various  new  growths  in 
the  pelvis  and  abdomen,  often  have  a  char- 
acteristic morphology  which  suggests  at  a 
glance  the  nature  of  the  patient's  disease  or 
condition.  To  inspect  the  abdomen  it  must 
be  entirely  exposed.  The  examiner  stands 
some  distance  off  and  looks  at  it  first  in  pro- 
file ;  then  from  the  patient's  knees.  In  obesity 
the  lower  abdominal  walls  rest  upon  the 
patient's  thighs.  In  ascites  the  abdominal 
surface  is  flat,  the  sides  bulge  outward.  A 
small  ovarian  cyst  may  distend  only  one  side 
of  the  abdomen  ;  a  fibroid  tumor  may  have  an 
irregular  surface,  or  if  it  is  symmetrical,  the 
outline  of  the  tumor  viewed  in  profile  is  bolder 
than  that  of  other  growths.  A  huge  cystic 
tumor  of  the  abdomen  is  probabh'  an  ovarian 
cyst;  a  tumor  distending  the  upper  abdomen 
alone  probably  springs  from  the  liver,  kidney,  spleen,  or  stomach. 

In  the  degree  of  tympanitic  distention  which  accompanies 
obstruction  of  the  bowels,  the  outline  of  the  coils  of  intestine 
may  be  seen.  Extreme  emaciation  usually  accompanies  a  large 
ovarian  cyst  or  a  malignant  tumor  with  ascites.  But  there  are 
numerous  exceptions  to  these  rules.  Ascites  and  hydramnios 
may  produce  as  excessive  and  as  uniform  a  distention  as  a  large 
ovarian  cyst.  The  latter  may  be  situated  in  the  upper  abdomen.^ 
A  fibromyoma  of  the  uterus  often  looks  surprisingly  like  a 
pregnant  uterus,  and  tympany  sometimes  shows  as  bold  an  out- 
line  as  a  fibroid   tumor.      While,  therefore,    considerable   value 


Fig.  29. — Ferguson's 
speculum. 


^  The  author  has  seen  an  ovarian  cyst  adherent  to  the  liver  in  pregnancy  and  held 
in  the  upper  abdomen  as  the  uterus  descended  during  involution  ;  also  an  ovarian 
tumor  displaced  under  the  floating  ribs  by  tight  lacing,  and  connected  with  the  broad 
ligament  by  a  very  long  pedicle. 


38 


The  Gynecological  Examination 


must   be   attached    to    the   outline   of  the   abdomen,   too    much 
dependence  must  not  be  placed  upon  mere  appearances. 

Percussion  and  Auscultation. — A  dull  or  t}'mpanitic  note  on 
the  percussion  of  the  abdominal  contents  has  the  greatest  sig- 
nificance ;  the  latter  indicates  a  solid  or  cystic  tumor;  the 
former,  distended  intestines.  It  should  be  remembered,  how- 
ever, that  inflated  intestines  may  prolapse  in  front  of  an  intra- 
abdominal tumor,  or  that  there  may  be  a  retroperitoneal  growth. 
Deep  percussion  is  necessary  in  such  a  case  to  detect  the  solid 

mass  beneath  the  bowels.  In 
ascites  there  is  tympany  on 
the  anterior  surface  of  the 
abdomen,  dullness  in  the 
flanks,  as  the  patient  lies  upon 
her  back.  The  fluid  gravi- 
tates to  the  lowest  portion  of 
the  abdominal  cavity,  so  that 
the  dullness  changes  with 
alterations  in  the  patient's 
posture.  In  an  ovarian  cyst 
there  is  dullness  on  the  ab- 
dominal surface  and  a  corona 
of  tympany  around  the  tumor 
on  the  flanks  and  in  the  epi- 
gastrium. 

Auscultation  is  employed 

in    the    differential     diagnosis 

between  pregnancy  and  other 

abdominal  tumors    to    detect 

the  fetal  heart-sounds  and  the 

funic  souffle.       The  so-called 

"  placental    bruit "    is    of    no 

diagnostic  value.      It   may  be 

heard    in    fibroid    tumors    as 

well  as  in  the  pregnant  uterus.      Auscultation  may  also  be  of  use 

in  the  diagnosis  of  peritonitis  to  detect  the  presence  or  absence 

of  peristalsis. 

Mensuration  of  the  Abdomen. — To  record  the  dimensions  of  an 
abdominal  tumor  or  to  determine  its  rate  of  growth,  abdominal 
measurements  are  taken  with  a  tape-measure,  preferably  in  the 
metric  scale.  The  greatest  girth  of  the  abdomen  is  measured  ; 
then  the  distances  between  the  ensiform  cartilage  and  the  umbili- 
cus ;  between  the  umbilicus  and  the  symphysis  pubis  ;  the  anterior 
superior  spines  of  the  ilia  ;  the  spines  of  the  ilia  and  the  sym- 
physis ;  the  spines  of  the  ilia  and  the  umbilicus.  , 


Fig.  30. — Measurements  of  the  ab 
domen  to  indicate  the  growth  of  an  ab 
dominal  tumor. 


Exploration  of  the  Uterine  Cavity 


39 


Exploration  of  the  Uterine  Cavity.— In  cases  of  metrorrhagia  it 
is  usually  necessary  to  explore  the  interior  of  the  uterus.  Often 
a  dilatation  of  the  cervical  canal  must  precede  the  intra-uterine 
exploration.  The  dilatation  of  the  canal  is  effected  by  branched 
dilators,  graduated  bougies,  tents,  and  gauze  or  cotton  packing. 
Branched  dilators  are  the  most  efficient  and  convenient  instru- 
ments for  the  purpose,  but  their  use  ordinarily  necessitates 
anesthetization.  If  the  os  is  fairly  patulous,  the  uterine  cavity 
may  be  explored  by  a  small   Sims'   curet   and  b}'  the   Emmet 


Fig.  31. — Sims'  sharp  curet. 

curetment  forceps,  the  fragments  removed  being  preserved  in 
a  10  per  cent,  formalin  solution  or  absolute  alcohol  for  micro- 
scopical examination.  In  some  respects  a  digital  exploration  of 
the  uterine  cavity  is  the  most  satisfactory,  but  such  a  wide 
dilatation  of  the  cervical  canal  is  required,  and  so  much  force  is 
needed  to  insert  a  forefinger  to  the  fundus  uteri,  that  anesthesia 
is  necessar}'. 

As  first  pointed  out  by  Vulliet,  the  uterine  cavity  may  be 
packed  with  small  pledgets  of  cotton  soaked  in  an  ethereal 
solution  of  iodoform,  to  each  of  which  a  string  is  attached.      By 


Fig.  32. — Emmet's  curet  forceps. 


continuing  the  packing  for  a  sufficient  length  of  time  from  day  to 
day,  the  uterine  cavit}'  is  not  only  open  to  touch,  but  actually 
to  inspection  as  far  as  the  fundus.  The  use  of  sponge,  tupelo, 
and  laminaria  tents,  while  a  very  convenient  mode  of  dilating  the 
cervical  canal,  is  not  usually  advisable,  for  the  danger  of  infection 
is  great.  Efforts  to  avoid  this  disadvantage  have  been  made 
by  surrounding  the  tents  with  rubber  tissue,  by  giving  them  a 
coating  of  soap  and  salicylic  acid,  and  by  soaking  laminaria  tents 
in  strong  solutions  of  carbolic  acid  in  alcohol,  but  even  with  these 
precautions  the  retention  in  the  cervix  and  uterine  cavity  of  soft 


40 


The  Gynecological  Examination 


and  spongy  material,  soaked  with  putrescible  discharges,  is  not 
safe.  The  other  methods  at  command  for  dilating  the  cervical 
canal  are  preferable.  It  is  very  rarely  useful  to  explore  the 
uterine  cavity  with  a  sound.  This  implement  at  one  time 
was  considered  indispensable  in  routine  gynecological  exam- 
inations   and    was    employed    in    almost    every    case.      It    was, 


Fig.  33. — Thomas'  uterine  probe. 


however,  productive  of  infection  in  numbers  of  instances.  As 
little  is  gained  by  the  insertion  of  such  an  instrument  into  the 
uterine  cavity,  and  as  from  its  employment  the  patient  is  subjected 
to  serious  risk  of  uterine  and  tubal  infection,  its  use  should  be 
limited  as  strictly  as  possible.  A  busy  gynecologist  should 
scarcely  employ  a  uterine  sound  once  in  six  months.      When  it  is 


Fig.  34. — Simpson's  uterine  sound. 

required,  it  should  be  steriHzed  by  boiling,  and  at  the  same  time 
a  bivalve  speculum,  a  cotton  forceps,  and  a  single  tenaculum 
must  be  prepared  in  the  same  way.  The  bivalve  speculum  is 
inserted  and  opened  widely.  The  cervix  is  pulled  down,  is 
steadied  by  the  tenaculum,  and  is  carefully  wiped  off  with  a 
pledget  of  cotton  on  a  cotton  forceps  soaked  in  a  1:1000  subli- 


•f^'g-  35- — Elliot's  cotton  forceps. 


mate  solution.  The  uterine  sound  is  tiien  inserted  directly  into 
the  external  os  through  the  speculum  without  touching  any- 
thing except  its  blades. 

In  addition  to  the  danger  of  infection,  the  sound  exposes  the 
woman  to  some  danger  of  perforation  of  the  uterine  wall.      It 


Exploration  of  the  Uterine   Cavity  41 

should  therefore  be  employed  gently,  and  no  forcible  pressure 
should  be  used  in  projecting  its  tip  against  the  fundus  uteri.  In 
cases  of  uterine  flexion  sufficient  curvature  must  be  imparted  to 
the  flexible  instrument  to  pass  the  angle  of  flexion  easily,  and 
care  must  be  exercised  to  employ  no  force  against  the  portion  of 
tiie  uterine  wall  opposite  the  angle  of  flexion.  In  anteflexion  it 
is  often  more  convenient  to  insert  the  sound  with  the  tip  turned 
downward  until  the  angle  of  flexion  is  reached,  then  by  a  rotary 
sweep  of  the  handle  the  point  is  turned  upward  and  so  enters  the 
uterine  cavity  to  its  full  depth.  A  reverse  movement  may  be 
employed  in  cases  of  retroflexion. 

An  effort  has  been   made  to  devise  a  uterine  endoscope  with 


t 

Fig.  36. — Outline  stamp  of  the  pelvic  cavity. 

practically   the    same    construction  as  a  urethroscope,  but    the 
instrument  is  not  yet  practical. 

Notes  of  every  case  examined  should  be  taken  and  should  be 
preserved  on  indexed  cards  or  in  indexed  case-books.  Even  the 
busiest  practitioner  can  find  the  time  if  he  cultivates  the  habit 
from  the  beginning.  The  essential  features  only  of  each  case 
need  be  recorded.  Diffuse  note -taking  is  often  a  waste  of 
time  and  may  lead  finally  to  the  neglect  of  case-histories 
altogether.  Dickinson's  rubber  stamps  of  the  pelvic  and  abdom- 
inal outlines  are  often  serviceable  for  the  brief  graphic  description 
of  a  condition.  Printed  forms  to  be  filled  out  are  not  to  be 
recommended,  because  they  are  too  inflexible,  and  to  meet  the 
requirements  of  every  possible  case  are  usually  too  long. 


42  The  Gynecological   Examination 


■f^'g-  37- — Outline  stamp  of  the  pelvic  cavity. 


DD 


Fig.  38. — Outline  stamp  of  the  pelvic  cavity. 


^'g-  39- — Outline  stamp  of  the  ])elvic  cavity. 


Vaginal   Douches 


43 


LOCAL  TREATMENT. 

The  local  palliative  treatment  of  diseases  of  the  pelvic  organs 
is  of  subordinate  importance.  The  routine  vaginal  and  intra- 
uterine applications,  once  the  greater  part  of  a  gynecologist's 
daily  work,  are  now  only  exceptionally  employed. 

Vaginal  douches  are  best  administered  from  a  fountain  or  a 
Davidson  syringe,  preferably  the 
former.  If  the  patient  gives  herself 
the  douche,  she  should  always  be 
warned  about  the  possible  dangers 
of  uterine  colic,  shock  and  infection. 
Deaths  are  reported  occasionally 
from  the  administration  of  a  vaginal 
douche.  The  syringe  bag  should 
not  be  more  than  three  feet  at  the 
most  above  the  level  of  the  vaginal 
orifice,  and  it  is  better  to  have  it  lower 
openings  on  the  side  and  not  at  the  end  should  always  be  em- 
ployed. The  nozzle  must  be  clean.  It  should  be  rinsed  out  in 
running  water  after  use  and  put  away  Avhere  it  can  not  become 
dusty  or  soiled.  Just  before  use  it  should  be  thrown  for  a 
moment  or  two  into  boiling  water,  or  should  be  kept  immersed 
in  a  sublimate  solution,  i  :  looo.     The  temperature  of  the  water 


Fig.  40.  —  Fountain  syringe. 

The  vasrinal  nozzle  with 


Fig.  41. — Household  bulb  syringe  (Davidson's). 


should  be  about  100°  F.,  unless  there  is  a  special  indication  for 
hot  douches,  when  it  should  be  from  115°  to  120°  F. 

The  vaginal  douche  is  most  effective  if  taken  in  the  dorsal 
position,  and  is  best  administered  by  a  nurse,  the  patient's 
buttocks  resting  upon  an  oblong  bedpan  of  considerable  depth, 
so  that  the  hips  are  slightly  elevated  and  there  is  ample  capacity 
in  the  pan  for  large  quantities  of  water.      The  ordinary  shovel- 


44  Local  Treatment 

shaped  bedpan  is  not  suitable.  If  the  patient  administers  the 
douche  herself,  the  easiest  way  for  her  to  take  it  in  the  recum- 
bent posture  is  in  a  bathtub,  although  with  a  little  practice  she 
can  manage  it  on  the  bedpan  as  described.  There  are  special 
devices  for  retaining  a  quantity  of  the  fluid  in  the  vagina  and 
allowing  it  to  escape  through  a  separate  exit  to  which  a  rubber 
tube  is  attached  that  can  be  led  into  a  receptacle  in  or  along- 
side of  the  bed.  Occasionally  such  a  device  is  convenient,  but 
ordinarily  the  retention  of  fluid  in  the  vagina  can  be  secured,  if 
desired,  by  holding  the  hand  over  the  vulvar  orifice  until  there  is 
some  distention  of  the  vaginal  canal.  This  practice,  however, 
entails  upon  the  patient  the  risk  of  injecting  fluid  into  the  uterine 
cavity,  causing  uterine  colic  and  possibly  serious  shock.  If  the 
Davidson  syringe  is  used,  the  patient  should  be  cautioned  not  to 
press  the  bulb  too  forcibly  or  suddenly.  The  medicinal  ingredi- 
ents of  a  douche  should  as  a  rule  be  the  milder  antiseptics,  such 
as  permanganate  of  potassium,  boracic  acid,  or  a  mixture  of 
alum  and  sulphate  of  zinc.      It  is  not  wise  to  prescribe  sublimate 


Fig.  42. — Douche  pan. 

solutions  indiscriminately.  Mistakes  may  be  made  in  the  strength 
of  the  solution,  and  the  patient  might  be  careless  about  washing 
out  the  residual  solution  at  the  close  of  the  douche  by  simple 
water.  Carbolic  acid  is  also  somewhat  dangerous  because  it 
may  not  mix  well  with  the  water  and  may  cause  severe  burns. 
A  vaginal  douche  should  not  be  prescribed  unless  there  is  some 
well-defined  indication  for  it,  and  its  routine  use  should  not  be 
permitted  indefinitely.  Many  patients  acquire  the  habit  of  con- 
-stantly  resorting  to  a  vaginal  douche  without  sufficient  cause.  It 
is  not  required  for  mere  cleanliness.  Nature  has  provided 
germicidal  properties  in  the  vaginal  canal  which  are  more  efficient 
safeguards  to  the  woman  than  injections  of  medicated  fluid. 

Intra=uterine  injections  should  always  be  administered  by  the 
physician  himself,  with  as  much  care  as  is  required  for  a  major 
operation.  The  instruments  used  should  be  boiled  and  he 
should  wear  .sterile  rubber  gloves.  Before  inserting  the  in- 
struments, the  vagina  should  be  scrubbed  with  tincture  of 
green  soap,  water,  and  pledgets  of  cotton,  and  should  be  douched 


Intrauterine  Injections 


45 


with  a  sublimate  solution,  i  :  4000,  washed  out  with  sterile  water. 
A  bivalve  speculum,  previously  boiled,  should  then  be  inserted 
and  widely  opened  so  that  the  cervix  is  well  exposed  to  view. 
The   vaginal   portion  of  the    cervix  should    be    wiped    off  with 


Fig.  43. — Fritsch's  intra-uterine  douche  :   L,  Inlet;    R,  outlet;    S,  screw  junction. 

pledgets  of  cotton  soaked  in  a  sublimate  solution  by  means  of  a 
dressing  forceps.  The  two-way  catheter  is  then  inserted  into  the 
uterine  cavity  until  its  tip  is  felt  to  impinge  against  the  fundus 
uteri.  Before  inserting  the  catheter,  fluid  should  be  allowed 
to  flow    through    it    so   that    no    air  shall  be  injected  into  the 


Fig.  44. — Talley's  intra-uterine  catheter. 

uterus  when  the  irrigation  is  begun.  The  best  two-way  catheter 
for  intra-uterine  injections  is  the  Fritsch-Bozeman.  Unfor- 
tunately, the  introduction  of  this  catheter  requires  a  patency  of 
the  cervical  canal  which  is  not  always  found  in  a  nulliparous 
woman.      If  it  is  necessary  to  administer  an  intra-uterine  irriga- 


Fig.  45. — Skene's  reflux  catheter. 


tion  in  a  woman  with  a  contracted  os  and  cervical  canal,  Talley's 
intra-uterine  or  Skene's  reflux  catheter  is  better  than  the  Fritsch- 
Bozeman,  but  none  of  the  catheters  designed  for  introduction 
through  an  undilated  canal  permit  of  as  free  a  reflux  as  they  ought. 


46  Local  Treatment 

and  there  is  always  danger  of  uterine  colic  and  regurgitation  of 
fluid  through  the  tubes.  It  is  better  to  precede  such  treatment 
by  a  forcible  dilatation  under  anesthesia.  If  at  the  same  time  a 
thorough  curettage  is  performed,  there  is  little  occasion  afterward 
for  the  repeated  irrigation  of  the  uterine  cavity.  The  tempera- 
ture of  the  water  for  an  intra-uterine  douche  should  be  about 
100°  F.  If  sublimate  solution  is  used,  it  should  invariably  be 
followed  by  at  least  a  pint  of  sterile  water.  The  force  of  the 
flow  should  not  be  too  great.  The  elevation  of  the  can  or 
syringe  bag  should  never  be  more  than  two  feet  above  the 
level  of  the  external  os,  and  if  there  is  doubt  as  to  the  free 
escape  of  the  fluid,  the  elevation  should  not  be  more  than  a  foot. 


Fig.   46. — Vaginal    tampon    of   lamb's    wool,   with    twine   tied    around    its    middle. 
When  the  loop  is  pulled  tight  the  end  is  long  enough  to  project  from  the  vagina. 

Vaginal  tampons  are  used  for  conveying  medication  and 
keeping  it  applied  to  the  vaginal  portion  of  the  cervix,  the  vagi- 
nal vaults,  and  the  vaginal  walls,  and  also  to  exert  pressure  upon 
the  vaginal  vault  and  the  superimposed  tissues.  The  best 
material  for  vaginal  tampons  is  lamb's  wool  in  bulk  and  not  in 
sheet  form.  Pledgets  of  the  wool  varying  in  size  are  tied  in  the 
middle  with  a  loop  of  twine  in  such  a  manner  that  the  knot  is 
hidden  in  the  wool,  leaving  the  loop  somewhat  more  than  the 
length  of  the  vagina,  so  that  the  tampon  can  easily  be  removed 
by  the  patient  herself,  who  hooks  her  finger  into  the  loop  and 
makes  traction  outward  and  forward.     The  tampon  material  should 


Vaginal  Tampons 


47 


be  sterile.  It  is  supplied  in  packages  which  are  said  by  the  makers 
to  contain  sterile  wool,  but  it  is  safer  to  have  the  material 
sterilized  before  use  in  an  autoclave  steam  sterilizer,  and  to  keep 
the  tampons  in  a  clean  glass  jar  with  a  well-fitting  top  that  pro- 
tects them  from  dust  or  other  contamination.  The  material  used 
to  medicate  the  tampons  is  usually  dry  boracic  acid  powder, 
boroglycerid,  glycerin  and  ichthyol,  six  parts  to  four,  and  tannic 
acid  powder.  The  tampons  are  inserted  through  a  bivalve 
speculum  if  they  are  designed  to 
carry  medication  into  the  deeper 
portions  of  the  vaginal  canal.  It 
it  is  desired  to  exert  pressure  on 
the  vaginal  vaults,  the  tampons 
should  be  inserted  with  the  patient 
in  the  knee-chest  posture.  A  Sims' 
speculum  is  used  to  retract  the 
perineum  and  posterior  vaginal 
wall,  and  the  tampons  are  packed 
in  with  an  Emmet  curetment  for- 
ceps held  with  the  convexity  up- 
ward. Each  tampon  is  dipped  in 
a  jar  of  dry  boracic  acid  powder 
before  it  is  inserted.  If  the  patient 
herself  must  insert  the  vaginal 
tampon,  it  is  most  convenient  to 
provide  her  with  gelatin  capsules 
that  are  made  to  contain  a  lamb's- 
wool  tampon  of  average  size.  In 
the  cup-shaped  top  of  this  capsule 
the  medication  required  can  be 
placed.       The     capsule      is      then 

closed,  is  anointed  with  an   unguent,  and  inserted  as  deeply  as 
possible  into  the  canal. 

Applications  to  the  mucous  membrane  of  the  vaginal 
vaults  and  walls  and  to  the  vaginal  portion  of  the  cervix  are 
made  by  the  introduction  of  tampons,  as  already  described,  or 
else,  after  the  exposure  of  the  vaginal  mucous  membrane  by  a 
speculum,  are  directly  made  by  a  pledget  of  absorbent  cotton 
held  in  dressing  forceps  and  saturated  with  whatever  medicament 
it  is  desired  to  apply.  lodin,  carbolic  acid  and  glycerin,  equal 
parts,  solutions  of  nitrate  of  silver  of  varying  strength,  weak 
solutions  of  chlorid  of  zinc  and  of  sulphate  of  copper  are  the  mate- 
rials ordinarily  employed.  A  bivalve  speculum  gives  the  best 
exposure  of  the  vaginal  portion  of  the  cervix  and  of  the  vaginal 
vaults.      The  cylindrical  speculum  also  exposes  the  cervix,  but  is 


Fig.  47. — Vaginal  tampon  in 
tin  capsule. 


rela- 


48 


Local  Treatment 


not  so  convenient.  The  best  speculum  for  the  exposure  at  the 
same  time  of  the  vaginal  portion  of  the  cervix,  the  vaults,  and  the 
vaginal  walls  is  the  skeleton  bivalve  speculum  made  in  the  shape  of 
a  Goodell  speculum,  of  narrow  tubing  and  without  solid  blades. 
Intra-uterine  Applications  and  Tamponade. — A  number  of 
appliances  are  available  for  the  application  of  medicaments  to  the 
uterine  mucous  membrane.  The  most  convenient  and  the  one  gen- 
erally employed  is  an  intra-uterine  applicator.  The  best  model  is 
the  Thomas.     Between  the  blades  of  the  forceps  a  small  pledget  of 


Fig.  48. — Thomas'  uterine  dressing  forceps. 

absorbent  cotton  is  caught  and  twisted  around  the  ends.  The  cervix 
is  exposed  with  a  bivalve  speculum,  is  wiped  off  with  a  pledget  of 
cotton  and  sublimate  solution,  is  caught  with  a  single  tenaculum, 
and  the  cotton  on  the  end  of  the  applicating  forceps,  saturated 
with  the  material  which  it  is  desired  to  introduce,  is  inserted  to 
the  fundus  uteri.  The  forceps  is  then  moved  from  side  to  side 
so  that  the  whole  uterine  mucosa  is  reached,  and  the  applicator 
is  allowed  to  remain  i7i  2Ltero  for  about  a  minute,  so  that  the 
material  with  which  the  cotton  is  saturated  has  time  to  trickle 
down  the  sides  of  the  uterine  cavity  and  appear  at  the  external 


Fig.  49. — Braun's  intra-uterine  syringe. 


OS.  Braun's  intra-uterine  syringe  is  also  a  convenient  implement 
for  conveying  liquids  to  the  uterine  mucosa,  but  it  has  the  disad- 
vantage of  often  exciting  severe  uterine  colic.  The  end  of  the 
syringe  should  always  be  wrapped  in  absorbent  cotton  so  that  the 
fluid  can  not  be  injected  into  the  uterine  cavity  too  suddenly  or  in 
too  large  quantities  ;  but  even  with  this  precaution  uterine  colic 
often  occurs.  The  Braun  syringe  should  never  be  used  unless 
the  cervical  canal  is  more  than  ordinarily  patulous.  A  convenient 
method  of  applying  medicaments  to  the  uterine  mucosa  is  the 
uterine  soluble  bougie,  which  is  most  conveniently  inserted  by  a 


Tamponade  of  the  Uterine  Cavity  49 

special  bougie  carrier  made  for  the  purpose.  It  is  also  possible  to 
insert  the  bougie  by  a  dressing  forceps  which  catches  the  end  of  it 
and  passes  it  directly  into  the  uterine  cavity.  The  bougies  can  be 
medicated,  as  the  physician  desires,with  astringents,  antiseptics,  and 
analgesics.  A  useful  prescription  is  one  of  protargol,  hydrastinin, 
and  small  quantities  of  morphin.  After  the  insertion  of  the  bougie 
a  vaginal  tampon  or  two  must  be  packed  firmly  against  the  cervix 
to  prevent  its  escape,  and  the  patient  should  maintain  the  dorsal 
position  with  elevated  hips  for  five  or  six  minutes.  A  corrugated 
bougie  is  sometimes  useful  for  carrying  unguents  into  the  uterus 
or  the  cervical  canal. 

A  tamponade  of  the  uterine  cavity  may  be  made  in  two 
ways.  The  best  is  to  insert  a  narrow  strip  of  gauze  from  half  an 
inch  to  an  inch  in  width  and  of  sufficient  length  to  fill  the  cavity 
completely.  The  cervix  is  exposed  with  a  bivalve  speculum,  is 
caught  with  a  single  tenaculum,  and  the  end  of  the  gauze  strip  is 


Fig.  50. — Bougie  carrier. 

seized  with  the  Thomas  applicating  forceps,  and  is  carried  to  the 
fundus  uteri.  Successive  portions  of  the  strip  are  then  seized  and 
inserted  until  the  cavity  is  completely  filled.  Special  applicators 
for  gauze  strip  tampons  are  made  on  the  same  principle  as  the 
bougie  carrier,  except  that  the  tip  of  the  piston  is  serrated  in 
order  to  catch  the  gauze  strip  more  securely.  The  gauze  is  fed 
into  the  distal  end  of  the  canula  and  is  carried  into  the  uterine 
cavity  by  a  pumping  movement  of  the  piston  within  it.  A  sim- 
pler appliance  is  a  cylindrical  speculum  with  a  handle,  for  inser- 
tion in  the  cervical  canal.  Through  this  the  gauze  is  packed 
by  any  straight,  slender  instrument.  Vulliet's  method  of 
tamponing  the  uterine  cavity,  is  to  insert  a  number  of  small 
cotton  balls,  each  with  a  piece  of  thin  twine  attached  to  it, 
soaked  in  an  ethereal  solution  of  iodoform,  and  dried.  It  is  pos- 
sible, by  renewing  the  application  of  these  cotton  balls  from  day 
to  day,  to  secure  a  wide  dilatation  of  the  uterine  cavity  and  of 
4 


50 


Local  Treatment 


the  cen'ical  canal  in  the  course  of  time,  but  there  is  risk,  in 
successive  intra-uterine  applications  of  this  kind,  of  dangerously- 
infecting  the  uterine  mucosa.  The  gauze  tampon  of  the  uterine 
cavity  may  be  saturated  with  liquid  or  dusted  with  powder,  but 
it  is  not  safe  to  make  repeated  intra-uterine  applications  which 
remain  in  utcro  for  any  length  of  time.  Indeed,  in  all  intra-uterine 
treatment  the  greatest  care  must  be  exercised  to  secure  the  most 
perfect  asepsis,  and  it  is  unwise  to  carry  out  intra-uterine  medica- 
tion of  any  sort  repeatedly  as  a  routine  treatment. 

Local  bloodletting  by  puncturing  the  cervix  is  often  indicated 
in  congestions  of  the  uterus  and  of  the  cervix,  to  relieve  acute 
symptoms  or  to  prepare  the  cervix  uteri  for  operative  treatment. 
The  best  means  of  depleting  the  womb  in  this  way  is  to  punc- 
ture the  cervix  with  Buttle' s  spear.  It  is  often  advisable  to  puncture 
retention  cysts  of  the  cervical  glands  by  this  implement.  Oc- 
casionally Kelly's  knife-bladed  tenaculum  is  more  convenient  for 


Fig.  51- — Buttle' s  scarificator. 


Fig.  52. — Kelly's  knife-blade  tenaculum. 


the  purpose,  as  it  may  reach  retention  cysts  within  the  cervical 
canal  that  can  not  so  readily  be  punctured  with  the  spear.  The 
use  of  leeches  is  a  common  practice  upon  the  continent  of  Europe, 
but  is  scarcely  ever  resorted  to  in  America.  It  is  a  disagreeable 
mode  of  treatment,  and  there  is  some  risk  of  a  leech  entering  the 
uterine  cavity.  The  same  results  can  be  more  conveniently  se- 
cured by  puncture  with  an  instrument. 

Electricity  is  an  invaluable  local  application  in  a  limited  num- 
ber of  conditions.  The  disappointment  following  electrical  treat- 
ment of  uterine  tumors  and  other  pathological  conditions  of  the 
genitalia  has  led  to  a  neglect  of  electrotherapeutics  in  gyne- 
cology. While  the  field  for  this  agent  is  a  limited  one,  there  are 
certain  conditions  which  can  be  dealtwith  more  successfullyby  elec- 
trical than  by  any  other  treatment.  The  application  of  the  posi- 
tive pole  of  a  galvanic  current  in  the  uterine  cavity  is  a  valuable 
hemo.static  agent.  The  negative  pole  of  a  galvanic  current  is  one  of 
the  best  treatments  for  amenorrhea.  Galvanism  and  faradism  of 
the  uterine  muscle  is  the  best  treatment  for  an  ill-developed  uterus. 


Electricity 


51 


Tt  is  often  necessary  to  apply  electricity  to  a  sphincter  ani  which  has 
been  injured  and  inactive  for  years,  though  successfully  repaired, 
and  a  bipolar  electrode  in  the  urethra  will  often  restore  con- 
tinence if  the  sphincter  of  the  bladder  and  the  compressor 
urethrae  muscle  are  partially  paralyzed  from  pressure  in  labor. 
An  electrical  cabinet  connected  with  the  street  current  and  de- 
signed  to   furnish   the   different  forms   of   electricity  in  varying 


FJg-  53- — Electrical  cabinet  for  supplying  from  the  street  current  galvanism, 
faradism,  and  cautery. 


strengths  is  an  indispensable  appliance  in  the  specialist's  office. 
A  bipolar  flexible  electrode  is  necessary  for  intra-uterine  and 
intra- urethral  applications.  A  unipolar  intra-uterine  electrode  is 
required  for  the  positive  and  negative  poles  of  a  galvanic  current. 
Bipolar  and  unipolar  electrodes  are  useful  for  anal  applications. 
A  cone-shaped  electrode  is  required  for  mild  cauterization  of  the 


52 


Local  Treatment 


cervix  in  cases  of  erosion.  A  large,  flat  sponge  electrode  must 
be  provided  if  strong  galvanic  currents  are  used  in  utcro.  For 
intra-uterine  applications  the  greatest  care  must  be  exercised  to 
secure  perfect  asepsis.  Much  unnecessary  discredit  has  been  cast 
upon  electrotherapeutics  in  gynecology  by  carelessness  in  this 
respect.  All  electrodes  for  intra-uterine  use  must  be  sterilized 
by  boiling  water.  They  should  be  made,  therefore,  of  platinum, 
webbing,  and  bone  or  lava,  so  that  they  shall  not  be  injured  in 
sterilization.      In  time  the  webbing  is  destroyed,  but  it  can  easily 


Fig.  54- — Large  sponge  electrode  for  the  abdomen. 


be  renewed.  To  insert  an  intra-uterine  electrode  a  bivalve  specu- 
lum mu.st  be  used,  the  cervix  must  be  wiped  off  with  pledgets 
of  cotton  soaked  in  sublimate  solution,  and  the  sterile  electrode 
passed  directly  into  the  uterine  cavity  without  touching  anything 
but  the  blades  of  the  speculum.  After  an  intra-uterine  applica- 
tion the  patient  should  remain  at  rest  for  half  an  hour  or  so,  and 
should  avoid  much  physical  effort  during  the  rest  of  the  day. 
The  electrical  appliances  should  include  a  small  cautery  knife 
and   cautery  points   for   the   removal    or   destruction   of  urethral 


Electricity 


53 


caruncles  and  of  venereal  warts,  which   can  be  accomplished  in 
office  practice  without  inconvenience  to  the  patient,  by  cocainiz- 


Fig.  55. — I,  Bipolar  anal  electrode; 
2,  bipolar  electrode  for  intra-uterine  far- 
adism  ;  3,  unipolar  intra-uterine  electrode. 


Fig.  56. — Small  cautery  knife. 


ing  the  small  growths  and  surrounding  tissues  before  the  cautery 
is  used. 


PART  II. 

ANOMALIES   OF    DEVELOPMENT  IN  THE  GENITAL 

TRACT, 

The  whole  genito-urinar}^  tract  of  the  female,  from  the  ova- 
ries to  the  entrance  of  the  vagina  and  to  the  bladder  and  urethra, 
may  be  absent,  in  part  or  wholly,  or  may  be  subject  to  more  or 
less  serious  developmental  anomalies,  disturbing  or  entirely  ab- 
rogating the  functions  of  the  affected  organs. 

The  ovaries  may  be  absent  or  ill  developed.  In  the  former 
case  there  is  usually  a  deficient  development  of  the  whole  gen- 
ital tract.  The  gland  itself  may  be  of  nearly  normal  size  and  in 
a  normal  situation,  but  the  gland-contents,  the  Graafian  follicles 
and  ovules,  may  be  absent,  or  the  egg-cords  of  the  fetal  ovary 
may  remain  in  their  primitive  condition.  The  opposite  anomaly 
of  development  by  excess  is  not  uncommon.  Accessory  ovaries 
immediately  adjoining  a  normal  ovary  and  included  usually 
within  the  same  epithelial  envelope  have  been  found  postmortem 
and  in  operations.  The  ovary  may  be  constricted  so  that  it  con- 
sists of  two  practically  independent  parts.  A  true  supernumerary 
ovary  far  removed  in  situation  from  its  fellows  is  extremely  rare. 
Winckel  reports  a  case  in  which  the  supernumerary  ovary  lay 
between  the  uterus  and  the  bladder.  The  possibility  of  acces- 
sory and  of  supernumerary  ovaries  must  be  taken  into  account 
in  the  operation  of  double  oophorectomy.  Cases  of  persistent 
menstruation  and  even  of  conception  after  such  operations  may  be 
thus  explained. 

The  Fallopian  tubes  show  a  number  of  developmental 
anomalies  of  interest  to  the  scientific  student,  but  of  little  impor- 
tance to  the  practical  gynecologist,  except  in  their  bearing  on  the 
etiology  of  tubal  gestation.  Accessory  fimbriated  extremities 
are  not  uncommon  ;  there  may  be  three  or  more  on  the  end  of  a 
single  tube.  An  accessory  uterine  orifice  is  also  not  extremely 
rare.  The  duct  of  the  tube  may  be  duplicated,  one  canal  com- 
monly lying  beneath  the  other.  In  connection  with  imperfect 
development  of  the  whole  sexual  apparatus,  the  tubes  may  also 
be  ill  developed;  they  may  possess  an  abnormally  small  caliber; 
they  may  be  solid,  without  any  lumen  at  all,  or  they  may  be  en- 
tirely absent.  On  the  contrary,  the  tube  may  show  an  abnor- 
mally   great    development    with    an   anomalous  patency  of   the 

54 


The  Uterus 


55 


canal,  allowing  the  easy  passage  of  a  sound  or  probe  from  the 
uterine  cavity  out  toward  the  abdominal  orifice  of  the  tube,  and 
likewise  permitting  the  regurgitation  of  fluids  into  the  abdominal 
cavity.  This  hyperplasia  of  the  tubes  is  not  uncommon  in  con- 
nection with  the  great  development  of  the  sexual  apparatus 
under  the  stimulus  of  pregnancy.  There  is  quite  often  a  regur- 
gitation of  lochial  discharge  in  small  quantities  into  the  peritoneal 
cavity  with  a  sharp,  transitory,  non-septic  peritonitis  as  a  result. 
The  tubes  may  be  congenitally  displaced,  usually  backward  and 
downward  into  Douglas's  pouch,  occasionally  forward  and  out- 
ward in  an  inguinal  hernia.  They 
may  be  obstructed  by  a  congenital 
angulation,  perhaps  interfering  with 
impregnation,  or  more  likely  retard- 
ing the  passage  of  the  impregnated 
ovule  toward  the  uterus,  and  thus 
causing  extra-uterine  pregnancy. 

The  Uterus. — There  are  many 
congenital  anomalies  of  the  uterus. 
They  follow,  however,  the  well- 
defined  lines  which  govern  con- 
genital deviations  from  the  normal 
in  the  fetal  and  infantile  body  as  a 
whole.  Kussmaul  and  Fiirst  first 
gave  a  full  and  clear  explanation 
of  the  developmental  anomalies 
affecting  the  uterus.  To  under- 
stand these  anomalies  it  is  neces- 
sary to  refer  briefl\"  to  its  embryo- 
genesis.  It  is  formed  by  the  junc- 
tion and  fusion  of  the  ducts  of 
Miiller,  accomplished  in  great  part 
before  the  twelfth  week  of  embry- 
onal life.     Until  the  twentieth  \veek 

of  the  embryo's  existence,  however,  there  still  remain  distinct 
traces  of  the  fusion  of  the  two  ducts,  the  uterus  in  this  period 
being  still  distinctly  bicornate.  After  the  twentieth  week,  and 
during  early  infancy,  the  uterus  presents  the  peculiarities  of  the 
so-called  fetal  uterus.  The  cervix  is  much  more  developed  than 
the  corpus,  and  the  mucous  membrane  of  the  cervical  canal  and 
of  the  uterine  cavity  is  thrown  into  numerous  folds.  After  the 
sixth  year  the  fundus  and  body  of  the  uterus  have  obviously 
attained  considerable  growth  in  comparison  with  the  cervix, 
though  there  is  nothing  like  the  preponderance  over  the  latter 
that  occurs  with  puberty. 


^'g-  57-  —  Diagrammatic  out- 
line of  the  Wolffian  bodies  and 
their  relation  to  the  ducts  of  Miiller 
and  the  reproductive  glands :  ot, 
Seat  of  origin  of  ovary  or  testes  ; 
7U,  Wolffian  body  ;  w.  Wolffian 
duct ;  7n,  t>i,  duct  of  Miiller  ;  gc, 
genital  cord  ;  tig,  urogenital  sinus  ; 
?',  rectum  ;  cl,  cloaca  (from  Allen 
Thompson). 


56      Anomalies  of  Development  in  Genital  Tract 

All  the  important  developmental  anomalies  of  the  Avomb  de- 
pend upon  an  arrest  of  development,  and  the  nature  of  these 
anomalies  depends  in  great  part  upon  the  time  at  which  the 
development  of  the  womb  was  arrested.  If  there  is  an  arrest  of 
the  fusion  of  iMiiller's  ducts  before  the  twelfth  week,  a  duplicit}'  of 
the  uterus  must  result.  If  the  arrest  of  fusion  in  the  two  canals 
occurs  after  the  twelfth  week,  a  bicornate  or  a  septate  uterus  is 
the  result.  If  the  disturbance  of  development  occurs  at  a  later 
period,  the  womb  retains  a  fetal  or  an  infantile  character,  without 
longitudinal  separation  or  distinct  indication  of  the  duplex  man- 
ner of  its  formation.  If  the  arrest  of  development  affects  the 
womb  at  a  very  early  period,  there  may  be  simply  a  rudimentary 
bundle  of  muscles  and  connective-tissue  fibers  to  indicate  its  sit- 
uation, and  in  extraordinary  cases  there  may  be  an  entire  absence 
of  the  organ. 

Absence  or  Rudimentary  Development  of  the  Uterus. — Complete 
absence  of  the  womb  is  extremely  rare,  although  an  examination 


Fig.  58. — Rudimentary  uterus  :  a.  Ribbon-shaped  rudiment  of  uterus  ;  b,  h,   round 
ligaments ;  c,  c,  Fallopian  tubes  ;  d,  d,  ovaries. 

during  life  may  fail  to  detect  the  slightest  sign  of  its  existence. 
After  death  is  found  an  indication,  at  least,  of  its  presence  in  a 
ribbon  of  muscle  or  connective  tissues  stretched  across  the  pelvis 
(Fig.  58),  or,  as  in  one  case,  in  a  mass  of  muscular  substance  on 
the  posterior  wall  of  the  bladder  (Fig.  59). 

A  rudimentary  development  of  the  uterus  is  not  common. 
There  may  be  a  solid  muscular  body  of  small  size  without  a 
cavity,  or  a  shallow  canal  leading  part-way  into  the  uterine  sub- 
stance. More  commonly  in  cases  of  arrested  development  the 
uterus  retains  in  adult  life  its  fetal  or  infantile  character.      A  dis- 


Infantile  Uterus  57 

tiiiction  is  often  drawn  between  the  fetal  and  infantile  uterus,  but 
for  practical  purposes  it  is  unnecessary. 

Non-development  of  the  uterus  is  commonly  associated  with 
acute  anteflexion  and  with  imperfect  development  of  the  nervous 
system.  A  very  large  proportion  of  hysterical  and  neurasthenic 
women  possess  an  infantile  uterus.  Usually  the  tubes  and 
ovaries  are  likewise  ill  developed,  but  occasionally  the  ovaries  are 
perfectly  normal  in  anatomical  development  and  in  physiological 
function, — an  unfortunate  condition, — for  the  periodical  activity 
of  the  ovaries  and  the  congestion  of  the  pelvis  are  unrelieved  by 
an  adequate  menstrual  discharge  from  the  infantile  uterus,  and 
individuals  thus  affected  suffer  severely  at  each  menstrual  epoch. 
Oophorectomy  is  indicated  if  the  woman  is  disabled  by  the 
severity  of  the  menstrual  molimina.  Women  with  ill-developed 
uteri  may  show  no  indication  of  the  defect  in  their  general  appear- 
ance, but  it  is  more  common  to  observe  ill  development  of  the 


Fig-  59- — Rudiment  of  uterus  on  pes-  Fig.  60. — Infantile  uterus, 

terior  wall  of  bladder  :   u,  Uterus. 

whole  organism,  a  small  stature,  a  slight  frame,  a  feebly  resisting 
nervous  system,  and  a  lack  of  mammary  development. 

The  local  treatment  of  an  ill-developed  uterus  is  unsatis- 
factory. If,  however,  it  is  not  too  marked  in  degree,  some 
advantage  is  occasionally  derived  from  the  use  of  the  faradic 
current  and  the  negative  pole  of  the  galvanic  current  applied 
in  the  uterine  cavity  ;  but  in  the  majority  of  cases  the  sterility 
and  the  scanty  menstruation  for  which  the  patient  consults  her 
physician  must  be  pronounced  incurable.  Occasionally  a  cure 
is  effected  by  repeated  conceptions.  The  uterus  does  not  expand 
sufficiently  at  first  to  permit  the  growth  of  a  fetus  to  term,  and 
there  are  repeated  miscarriages  until  the  fourth  or  fifth  preg- 
nancy, which  may  go  to  full  time. 

Arrested  Development  of   One  of  the  Ducts  of   Miiller  (Uterus 


58      Anomalies  of  Development  in  Genital  Tract 

Unicornis). — There  may  be  an  arrest  of  development  or  a  failure 
to  appear  on  the  part  of  a  Miiller's  duct,  with  the  consequent  for- 
mation of  but  one  side  of  the  womb  and  a  development  of  but 
one  Fallopian  tube.      Both  ovaries  may  be  present.      It  is  more 


Fig.  61. — Uterus  unicornis:  LH,  Left  horn;  LT,  left  tube;  Lo,  left  ovary 
Z  Lr,  left  round  ligament;  RH,  right  horn;  KT,  right  tube;  Ro,  right  ovary: 
R  Lr,  right  round  ligament. 


Fig.  62. — Ill-developed  uterus  unicornis:  a.  Cervix;  b,  fundus;  c,  d,  longi- 
tudinal axis  of  uterine  body  ;  e,  cornu  ;  f,  tube  ;  g,  ovary  ;  h,  ovarian  ligament .; 
i,  round  ligament ;  k,  parovarium. 


Fig.  63. — 111  development  of  right  side  of  uterus;  congenital  lateral  flexion. 


common  to  see  an  indication  of  an  ill-developed  Miillerian  duct 
on  one  side  in  the  shape  of  a  solid  muscular  band  which  runs 
outward  to  the  insertion  of  the  round  ligament  (Fig.  61).  The 
unicorn  uterus  is  situated  entirely  on   one  side  of  the  axis  of  the 


Double  Uterus 


59 


pelvic  cavity,  and  it  inclines  sharply  toward  the  corresponding 
pelvic  wall.  There  is  no  uterine  fundus,  and  the  uterine  body 
ends  in  a  cone-shaped  projection  in  which  is  inserted  the  Fallo- 
pian tube.  In  slight  degrees  of  arrested  development  on  one 
side  the  uterus  may  show  a  lateral  flexion  toward  the  undeveloped 
side.  These  conditions  do  not  call  for  gynecological  treatment. 
They  are  only  detected,  if  recognized  at  all,  in  the  course  of  a  pelvic 
examination  for  suspected  pregnancy  or  for  pelvic  pain.  The 
situation  of  the  uterus  on  one  side  of  the  pelvis  may  lead  to  the 
mistaken  diagnosis  of  tubal  gestation.  If  the  unicorn  uterus  is 
displaced  and  adherent  it  may  be  taken  for  a  pus-tube. 


Fig.  64.  Fig.  65 

Figs.  64  and  65. — Uterus  didelphys  :  a.  Right  segment;  b,  left  segment;  c,  d, 
right  ovary  and  round  ligament ;  f,  e,  left  ovary  and  round  ligament ;  g,  J,  left  cervix 
and  vagina;  k,  vaginal  septum  ;   /;,  ?',  right  cervix  and  vagina. 


Arrested  Fusion  of  the  Ducts  of  Miiller.  Uterus  Didelphys ; 
Double  Uterus. — Occasionally  the  ducts  of  Miiller  remain  en- 
tirely apart  from  each  other  in  the  whole  course  of  their  devel- 
opment, the  failure  of  union  resulting  in  the  formation  of  two 
distinct  uterine  bodies,  without  even  external  junction.  There 
are  two  cervices  and  two  distinct  vaginal  canals,  though  the 
latter  always  lie  in  juxtaposition  to  each  other  (Figs.  64  and  65). 
It  was  thought  at  one  time  that  this  was  an  extremely  rare 
variety  of  duplex  formation  in  the  uterus,  but  by  a  more  careful 
examination  of  patients  during  life,  and  a  more  careful  observa- 
tion of  specimens  postmortem,  the  number  of  these  cases  has 
lately  grown  considerably,  and  it  is  a  question  if  many  of  the 


Fig.  66. — Uterus  bicornis  duplex  :  a,  a,  Double  entrance  to  vagina ;  b,  meatus 
urinarius  ;  c,  clitoris  ;  d,  urethra  ;  e,  e,  double  vagina  ;  f,f,  external  orifices  of  uterus; 
g,  g,  double  cervix  ;  h,  h,  bodies  and  horns  of  uterus  ;  i,  i,  ovaries  ;  k,  k,  tubes  ; 
/,  /,  round  ligaments  ;  w,  m,  broad  ligaments. 


R 

^^H 

H 

p 

1" 

^■| 

1^ 

Wf^ 

^^r 

1 

^^^^H 

Fig.  67. — Uterus  bicornis  unicollis  (Hodge  collection,  Univ.  of  Penna.). 

60 


Uterus   Bicornis 


6i 


examples  of  uterus  bicornis  should  not  be  included  under  the 
heading  of  double  uterus  or  uterus  didelphys. 

During  life  the  diagnosis  of  complete  separation  of  the  two 
uterine  bodies  can  be  made  by  the  introduction  of  the  sound  into 
each  and  the  observation  that  one  moves  entirely  independently 
of  the  other.  Bimanual  palpation  may  also  furnish  the  same 
information. 

Uterus  Bicornis  Duplex. — The  two  bodies  of  the  uterus  are  in 
juxtaposition  and  are  connected  externally,  but  remain  internally 
distinct  and  apart  through  their  whole  length,  and  are  joined 
externally  not  so  much  by  muscular  tissue  as  by  their  peritoneal 


Fig.  68. — Uterus  cordiformis  :  a.  Indented  fundus  ;  b,  b,  tubes  ;  c,  c,  round  liga- 
ments ;  d,  central  longitudinal  ridge  on  posterior  wall  of  uterine  cavity  ;  e,  e,  lateral 
ridges  of  same  ;  f,  internal  os  ;  g,  g,  cervix. 


investment  and  connective  tissue.  There  are  two  distinct  uterine 
cavities,  two  cervices,  and  a  double  vagina. 

Uterus  Bicornis  Unicollis  (Bifid  Uterus). — The  junction  of  the 
two  ducts  is  quite  intimate  below,  so  that  there  may  be  a  single 
cervix  without  a  dividing  septum  ;  but  directly  above  the  two 
uterine  halves  diverge  sharply  from  each  other.  It  may  not  be 
easy  to  recognize  this  condition  during  life,  but  it  is  possible  to 
do  so  by  a  careful  bimanual  examination,  followed  by  the  use  of 
the  uterine  sound,  which  detects  the  divergence  of  the  uterine 
canals.  If  the  bifid  uterus  is  retroverted  and  firmly  fixed  by 
inflammatory  adhesions,  it  maybe  taken  for  a  double  pyosalpinx. 

In  uterus  cordiformis  the  fundus  is  broad,  and  the  uterus  has 
a  conventional  heart  shape.  Associated  with  this  external  appear- 
ance there  may  be  a  longitudinal  septum  wathin  the  uterine  cavity. 


62      Anomalies  of  Development  in  Genital  Tract 

uterus  incudiformis  is  an  exaggeration  of  the  uterus  cordi- 
formis  without  the  median  depression  in  the  fundus.  The  upper 
portion  of  the  uterus  is  expanded  laterally,  so  that  the  whole 
organ  has  the  shape  of  an  anvil. 


Fig.  69. — Uterus  incudiformis. 


Fig.  71. — Uterus  septus  (Greuzel). 


Fig.  70. — Uterus  septus:  a,  a. 
Tubes  ;  h,  h,  fundus  uteri ;  c,  c,  c,  sep- 
tum ;  d,  d,  the  cavities  of  the  two 
uteri  ;  e,  e,  internal  os ;  f,  f,  external 
wall  of  the  two  cervices  ;  g,  g,  external 
orifice  ;  h,  h,  vagina  ;  /,  vaginal  sep- 
tum. 


Fig.  72. — Schematic  drawing  of 
double  vagina  and  single  uterus :  Ay 
Left  vagina  ;  B,  right  vagina ;  C,  cer- 
vical septum. 


Uterus  Septus,  Subseptus,  Partitus,  Semi-partitus. — With  or 
without  any  external  manifestation  of  imperfect  fusion  of  Muller's 
ducts,  there  may  be  in  the  interior  of.  the  uterus  a  longitudinal 
septum  dividing  the  cavity  in  whole  or  in  part.  The  two  divi- 
sions of  the  womb  in  a  uterus  septus  are  commonly  of  unequal 


Anomalies  of  Development  in   the   Cervix         63 

size  or  development.  One  is  usually  smaller  and  less  developed 
than  the  other. 

The  vagina  is  divided  by  a  longitudinal  septum  in  cases  of 
uterus  didelphys,  uterus  bicornis  duplex,  and  sometimes  in  uterus 
subseptus.  The  vagina  and  cervix  (uterus  biforis)  may  be 
divided  longitudinally  without  division  of  the  uterine  cavity. 

Anomalies  of  Development  in  tlie  Cervix.^ — The  commonest 
developmental  anomaly  in  the  cervix  is  a  stenosis  of  the  canal 
and  of  the  external  and  internal  os,  associated  frequently  with  a 
small  and  conical  cervix,  and  often  with  an  undersized  and  ante- 
flexed  uterus.  The  narrow  cervical  canal  and  the  angle  of 
flexion  in  the  lower  uterine  segment  directly  above  it  oppose  a 
mechanical  obstacle  to  the  escape  of  blood  at  the  menstrual 
period.  For  the  first  few  years  after  puberty  there  may  be  very 
little  pain  ;  but  as  the  menstrual  flow  increases,  there  is  greater 
difficulty  in  its  discharge  ;  the  disturbance  of  the  uterus,  its  dis- 
tention, and  the  violent  muscular  action  required  to  expel  the 
blood  irritate  the  lining  membrane,  which  in  time  becomes 
chronically  congested.  This  condition  leads  to  a  sudden  onset 
of  menstruation,  with  a  more  profuse  flow,  which,  of  course, 
increases  the  difficulty,  and  so  a  vicious  circle  is  established  that 
causes  greater  suffering  at  each  period,  intermenstrual  pain,  and 
at  length  a  complete  nervous  breakdown.      (See  Dysmenorrhea.) 

Atresia  of  the  Cervix. — Congenital  atresia  of  the  cervix  may 
have  its  seat  at  the  internal  or  at  the  external  os,  or  it  may  affect 
the  whole  canal.  It  is  not  discovered  until  after  puberty  and  the 
institution  of  menstruation.  If  there  is  no  associated  anomaly 
of  the  uterine  body  or  ovaries,  the  menstrual  molimina  appear 
regularly  and  become  more  painful  without  the  discharge  of 
blood  from  the  genitalia.  By  a  bimanual  examination  the  phy- 
sician detects  a  spherical  cystic  tumor  in  the  pelvis,  occupying 
the  position  of  the  uterus.  By  a  specular  examination  the 
closure  of  the  external  canal  and  the  distention  of  the  cervix 
may  be  seen,  or  if  the  atresia  is  higher  up  it  is  detected  by  a 
sound.  Exceptionally  there  is  no  attempt  at  menstruation,  and 
occasionally  the  menstruation  is  vicarious. 

The  diagnosis  of  congenital  atresia  of  the  cervix  is  easily 
made.  It  is  impossible  to  pass  a  sound  through  the  cervical 
canal.  If  there  has  been  an  accumulation  of  menstrual  fluid  or 
of  mucus  within  the  womb,  the  latter  is  converted  into  a  cystic 
tumor  with  rather  thick  walls,  and  on  both  sides  of  it  there 
may  be  enlarged  and  distended  tubes.  In  atresia  at  the  inter- 
nal OS  the  external  form  of  the  cervix  is  well  preserved.  In 
atresia  at  the  external  os  the  cervix  is  practically  obliterated  and 
becomes  continuous  with  the  vaginal  vault.      By  digital  exami- 


64      Anomalies  of  Development  in   Genital  Tract 

nation  it  is  impossible  to  detect  the  cervix,  but  upon  inspection 
through  a  speculum  it  is  indicated  by  a  slightly  projecting  nipple 
in  the  middle  of  the  vaginal  vault,  and  the  seat  of  the  external  os 
is  marked  by  a  shallow  dimple.  Landau  and  Pick  ^  report  a  case 
of  congenital  gynatresia  in  which  the  cervix  was  replaced  by  an 
imperforate  adenomyoma  derived  from  the  Wolffian  body. 

(For  the  treatmejit  see  Hematometra.) 

Arrested  Development  of  the  Cervix. — The  cervix  may  be  un- 
developed in  common  with  ill  development  of  the  uterus  or  of  the 
whole  genital  apparatus.  Occasionally  the  cervix  alone  is  affected, 
and  in  exceptional  instances  the  whole   vaginal   portion   may  be 


-^4^^,\ 


Fig.  73. — Hypertrophic  elongation 
of  the  cervix  :  a,  Cervix  ;  b,  c,  ante- 
rior and  posterior  lips  ;  d,  uterine  body. 


Fig.  74. — Hypertrophic  elongation 
of  the  cervix  and  prolapsus  :  a,  Cervix  ; 
b,  uterine  body  ;   c,  meatus. 


lacking,  while  the  rest  of  the  genital  canal  is  well  developed.  In 
these  cases  the  vagina  passes  directly  into  the  uterine  cavity  by  a 
small  constricted  opening.  It  is  easy  to  confound  with  this  con- 
dition a  congenital  stenosis  of  the  upper  third  of  the  vagina,  in  which 
the  canal  is  suddenly  reduced  to  a  small  sinus  barely  admitting  the 
uterine  sound,  or  a  transverse  perforate  septum  in  the  vagina. 
Hypertrophy  of  the  Cervix. — The  vaginal  portion  of  the  cervix 
occasionally  shows  marked  hypertiophy,  presumably  of  con- 
genital origin.  There  is  no  inversion  of  the  vaginal  mucous 
membrane,  yet  the  cervix  reaches  to  and  projects  beyond  the 
vulva.  It  has  a  conical  shape,  with  a  broad  base,  but  that  portion 
of  it  which  appears  between  the  labia  has  a  normal  appearance 
in   shape  and   size.      There   is   no  ulceration  around  the  os,  no 

1  "Arch.  f.  Gyn.,"  Bd.  Ixiv,  II.  i. 


The  Vao-ina 


65 


marked  increase  in  the  transverse  diameter ;  in  short,  there  are  none 
of  those  changes  which  are  common  when  the  cervix  is  prolapsed 
in  consequence  of  inversion  of  the  vaginal  walls  and  supravaginal 
elongation,  the  latter  being  usually  due  to  some  of  the  injuries  of 
childbirth,  and  having  no  place  among  the  congenital  anomalies 
of  this  region.  Hypertrophy  of  the  infravaginal  portion  of  the 
cervix  is  more  common  in  negresses  than  in  white  women. 

The  U^eatment  is  amputation  of  the  cervix  at  the  level  of  the 
vaginal  vault.      (See  page  210,) 


Fig-  75- — Congenital  absence  of  the  vagina. 


The  vagina  may  be  absent  or  indicated  only  by  a  rudimentary 
cord  of  connective  tissue.  This  condition  may  be  associated 
with  an  absence  of  the  whole  internal  genitalia,  while  the  exter- 
nal genitals  may  present  a  perfectly  normal  appearance.  If 
the  uterus  and  ovaries  are  well  developed,  the  absence  of  the 
vagina  gives  rise  to  serious  trouble  as  soon  as  menstruation 
begins.  The  menstrual  fluid  collects  within  the  womb,  accu- 
mulating also  in  the  tubes,  which  before  long  threaten  to  rup- 
ture. By  a  bimanual  examination  of  the  rectum  and  abdo- 
men, the  distended  uterus  and  the  tubes  may  be  detected  high 
up  in  the  pelvic  cavity  or  above  it.  The  thickness  of  the  tissue 
representing  the  vagina,  or  the  entire  absence  of  such  tissue,  can 
5 


66      Anomalies  of  Development  in  Genital  Tract 

be  determined  by  a  sound  in  the  bladder  and  a  finger  in  the  rec- 
tum. A  passageway  must  be  opened  for  the  escape  of  the 
retained  menstrual  blood  by  making  a  transverse  incision  in  the 
perineum  between  the  rectum  and  the  urethra,  and  then  a  blunt 
dissection  upward  until  the  cervix  is  reached.  The  rectum  and 
bladder  are  guarded  from  injury  by  a  bougie  in  one  and  a  sound 
in  the  other.  The  uterus,  when  it  is  reached,  is  punctured  with  a 
trocar  and  the  thick  sanguinolent  fluid  is  allowed  to  escape  slowly, 


i 

0k 

^^^ 

\ 

fJ 

w^^- 

l.V 

^ 

w 

Fig.  76. — Congenital  absence  of  the  vagina. 


long-continued  irrigation  of  the  uterine  cavity  with  boracic  acid 
solution  and  packing  with  iodoform  gauze  following  the  evacuation 
of  the  uterus.  If  the  tubes  are  di.stended,  an  abdominal  section 
and  their  removal  should  precede  the  vaginal  operation.  The 
numerous  fatal  cases  of  peritonitis  following  operation  for  gyn- 
atresia are  due  to  the  putrefaction  of  the  fluid  in  the  distended 
tubes  or  to  their  rupture.  The  artificial  vagina  is  kept  open  with 
great  difficulty  after  such  an  operation.  The  best  means  is  to 
transpose  a  flap  of  skin  from  the  labia  majora  or  buttocks  into 


Absence  of  Vao^^ina 


67 


the  vagina,  sewing  the  ends,  if  possible,  to  the  cervix.  Per- 
sistent and  frequent  dilatation  with  cylindrical  dilators  must  fol- 
low. In  spite  of  all  these  efforts,  however,  the  artificial  opening 
may  close  again,  or  may  become  so  contracted  as  to  oppose  a 
serious  mechanical  obstacle  to  the  escape  of  the  menstrual  fluid. 
It  may  be  possible  to  use  packing  persistently,  or  to  insert  a 
metal,  hard-rubber,  or  glass  tube  (Sims'  plug)  which  shall  be 
continuously  worn.  In  one  case,  quoted  by  Pozzi,  temporary  suc- 
cess was  attained,  after  making  the  artificial  vagina,  by  electrolysis. 


Fig.  77. — Implantation  of  the  vagina:  /,  Mucous  membrane  from  a  case  of 
prolapsus  uteri  implanted  in  a  woman  with  congenital  absence  of  the  vagina  (Howard 
Hospital). 


If  there  is  absence  or  non-development  of  the  uterus,  so  that 
menstruation  does  not  occur,  it  is  usually  unjustifiable  to  make 
an  artificial  vagina  simply  to  permit  copulation.  The  mere  mak- 
ing of  the  artificial  vagina  is  easy  enough  (see  page  144).  Should 
there  be  well-developed  ovaries  with  absence  of  the  vagina  and 
uterus,  so  that  there  are  menstrual  molimina,  associated  with  great 
pain  and  nervous  distress,  oophorectomy  may  be  called  for.  In  a 
few  cases  of  absent  vagina  and  uterus  there  has  been  vicarious  men- 
struation, the  blood  being  discharged  from  the  mucous  membranes 


6S      Anomalies  of  Development  in  Genital  Tract 


Fig.  78. — Three  weeks  after  operation  for  artificial  vagina  and  implantation  of  vaginal 
mucous  membrane.     Speculum  inserted  three  inches. 


Fig-  79- — Silver  plug  (Sims')  supported  by  abdominal  belt  and  rubber  bands. 


Unilateral  and  Double  Vaginae 


69 


of  the  stomach  and    of   the    lungs,  and  in  one  case  through  the 
skin  of  the  extremities. 

Occasionally  the  vagina  is  absent  in  only  a  part  of  its  course, 
being  reduced  to  a  solid  fibrous  cord  at  about  the  middle.  The 
menstrual  fluid  after  puberty  is  retained,  first  distending  the 
vaginal  canal  above  the  point  of  atresia,  then  dilating  the 
uterine  cavity,  and  finally  the  tubes.  This  condition  is  easily 
managed  by  operative  treatment,  the  mucous  membrane  of  the 
upper  vagina  being  united  to  that  of  the  lower  canal.  Atresia 
of  the  vagina  may  result  if  the  depression 
between  the  labia  fails  to  unite  with  the 
vaginal  canal  in  embryonal  development. 
The  two  passageways  impinge  upon  each 
other,  but  the  barrier  between  them  fails 
to  melt  away  as  it  should.  In  such  a 
case  the  urogenital  fissure  is  much  deeper 
than  common,  but  the  accumulated  fluid 
behind  the  barrier  which  prevents  its  escape 
is  within  easy  reach  and  its  evacuation  is 
attended  with  no  special  difficulties.  After 
making  a  free  opening  or,  if  necessary,  a 
dissection  upward  to  reach  the  vaginal 
canal,  the  mucous  membrane  of  the  vagina 
may  be  pulled  down  and  stitched  to  the 
skin  of  the  vulva. 

Unilateral  Vagina. — It  sometimes  hap- 
pens that  one  of  the  two  Miiller's  ducts 
which,  when  fused  together,  constitute  the 
normal  vagina,  fails  to  develop  entirely,  and 
the  vagina  is  formed  by  the  growth  of  but 
a  single  duct.  It  is  doubtful  if  a  unilateral 
vagina  ever  occurs  except  with  a  unicorn 

uterus.      The  vaginal  canal  is  much  narrower  than  common,  and 
may  be  situated  to  one  side  of  the  median  line. 

Double  Vagina. — There  may  be  a  failure  of  fusion  of  the  two 
Miiller's  ducts  in  their  lower  portions,  as  there  is  a  failure  of 
fusion  above  in  the  different  forms  of  double  or  septate  womb. 
The  septum  of  the  double  vagina  is  so  arranged  that  one  canal 
is  somewhat  anterior  to  the  other.  The  septum  usually  extends 
the  whole  length  of  the  vagina  and  is  often  associated  with  a 
double  hymen.  In  some  cases,  however,  the  septum  may  be 
lacking  in  part.  The  hymen  may  be  single,  and  there  may  be  a 
considerable  space  between  it  and  the  commencement  of  the 
vaginal  septum.  Occasionally  the  double  vagina  is  asymmetrical, 
one  of  the  canals  being  larger  and  better  developed  than   the 


Fig.  80. — Stitching 
vaginal  walls  to  external 
skin  (Kelly). 


JO      Anomalies  of  Development  in  Genital  Tract 


other.  In  such  a  case  the  smaller  canal  may  be  closed  at  its 
lower  end.  After  puberty  a  lateral  hematocolpos  may  appear  if 
the  undeveloped  vaginal  canal  is  connected  with  one  side  of  a 
double  uterus. 

A  double  vagina  is  often  overlooked.  In  the  case  of  lateral 
hematocolpos  from  atresia  of  one  side  of  a  double  vagina,  the 
diagnosis    may  be    difficult,   and    is  made    only   after    a   careful 

bimanual  and  rectal  exam- 
ination, and  possibly  only 
after  a  free  incision  into  the 
vaginal  wall  and  the  evacu- 
ation of  the  accumulated 
fluid. 


Fig.  8i. — Double  vagina. 


Fig.  82. — Longitudinal  band  divid- 
ing vaginal  orilice. 


Stenosis  of  the  Vagina.— There  may  be  narrowing  of  the  whole 
vaginal  canal  associated  with  ill  development  of  the  entire  genital 
tract.  Occasionally  the  vagina  in  its  upper  third  is  reduced  to  a 
small  sinus  no  larger  than  a  cervical  canal,  the  vagina  suddenly 
ending  at  a  distance  of  an  inch  or  more  below  the  cervix.  The 
vagina  may  likewise  be  obstructed  by  transverse  folds  of  mu- 
cous membrane  and  connective  tissue,  in  some  cases  simulating 
a  second  hymen  high  up  in  the  canal,  in  others  taking  the 
form  of  thick,  fleshy,  transverse  bands.  ^  Occasionally  these 
bands  run  anteroposteriorly. 

'The  author  has  seen  two  cases  lately  in  which  the  vagina  ended  apparently  in  a 
normal  vault  about  two-thirds  the  way  up.  To  the  left  of  the  median  line  was  a 
slit  into  which  the  forefinger  could  be  passed.  Beyond  this  point  the  vagina  again 
expanded  into  its  pn^per  width,  with  the  cervix  projecting  normally  from  its  vault. 


The  Vulva 


71 


The  Vulva. — At  the  end  of  the  first  month  of  the  embryo's 
existence  a  depression  is  developed  in  the  caudal  region,  growing 
deeper  toward  the  allantois  and  opening  into  the  latter,  and  con- 
sequently into  the  intestines,  to  which  it  is  joined,  constituting 
the  common  opening,  the  so-called  cloaca.  A  few  days  later  the 
first  indication  of  the  sexual  organs  appears  in  the  shape  of  a 
sligfht  eminence  above  the  cloaca,  and  on  either  side  of  this 
eminence  appears  a  fold  of  skin.  In  the  course  of  the  next  two 
weeks  the  wall  partly  separating  the  intestines  and  allantois 
grows  downward  into  the  cloaca,  and,  being  met  by  a  process 
from  the  external  skin  growing  upward,  forms  the  perineum  and 
divides  the  genital  from  the  intestinal  canal.  The  genital  emi- 
nence becomes  later  the  clitoris ;  the  folds  of  skin  on  either  side, 


cl  -  ^ 

Fig.  83  Fig.  84.  Fig.  85.  Fig.  86. 

Fig.  83. — cl.  Cloaca  which  has  opened  into  primitive  hind-gut,  and  commu- 
nicates with  the  rectum  and  allantois  ;  the  posterior  portion,  all,  of  the  latter  has 
commenced  to  dilate  to  form  the  urinary  bladder  ;  ;//,  duct  of  Miiller  ;   ;',  rectum. 

Fig.  84. — The  cloaca  has  divided  into  a  ventral  portion,  su,  the  urogenital  sinus, 
which  communicates  ventrally  with  the  urethra,  it,  and  the  bladder,  b,  and  more 
dorsally  with  v,  the  vagina,  formed  by  fusion  of  the  ducts  of  Miiller ;  ;-,  rectum. 

Fig.  85. —  1  he  perineum  or  tissues  separating  the  rectum  from  the  urogenital 
sinus  are  well  developed  ;  the  neck  of  the  bladder  has  become  constricted  to  form  the 
primitive  urethra,  and  is  separated  from  the  vaginal  passage,  though  both  open  into 
the  common  urogenital  sinus,  .r,  and  the  clitoris,  c  (in  the  male  the  rudiment  of  the 
penis),  has  appeared  ;  r,  rectum. 

Fig.  86. — The  urogenital  sinus  of  the  female,  s,  remains  as  the  cleft  between  the 
sides  of  the  external  aperture  of  the  labia  minora ;  it  communicates  in  front  with  the 
bladder,  b,  and  dorsally  with  the  vagina,  v  ;  r,  rectum. 


the  labia  majora.  Within  these  are  developed  the  nymphae  or 
labia  minora.  Anteriorly  the  urethra  is  now  formed,  and  a 
septum  divides  the  urinary  from  the  genital  tract.  The  ducts  of 
Miiller  descend,  making  the  urogenital  sinus,  as  the  common 
external  opening  is  called,  more  shallow. 

Atresia  of  the  Vulva.— Very  rarely  there  is  an  entire  absence 
of  the  successive  steps  in  development  by  which  the  urogenital 
sinus  is  formed,  and  the  skin  is  stretched  evenly  and  unbroken 
from  the  pubes  to  the  coccyx  and  from  one  tuberosity  of  the 
ischium  to  the  other.  There  is  complete  atresia  of  the  vulva 
and  of  the  anus.      Such  a  fetus  is  non-viable. 

Arrested  Development  of  the  Urogenital  Sinus.— An  arrest  in  the 
development  of  the  urogenital  sinus  occasionally  results  in  a  per- 


72      Anomalies  of  Development  in  Genital  Tract 


sistence  of  the  conditions  that  existed  at  the  stage  of  embryonal 
development  when  the  openings  of  the  intestine,  bladder,  and 
genital  tract  were  common  and  unseparated.  There  may  be  thus 
hypospadias  in  the  female,  which  is,  however,  very  rare,  or  more 
commonly  an  anomalous  opening  of  the  bowel  in  the  fossa 
naviculars.  To  this  condition  the  name  of  atresia  ani  vaginalis 
is  commonly  given,  a  name  not  strictly  accurate,  for  there  is,  of 
course,  not  a  complete  atresia  of  the  anus,  but  simply  an  abnor- 
mal position.  Rarely  there  may  be,  coincident  with  this  abnor- 
mal opening  of  tlie  bowel,  a  patent  anus  in  the  normal  situation. 
Hyperplasia  and  Hypertrophy  of  the  Vulva. — Hypertrophy  of 
the  labia  majora  is  rare.  The  author  has  seen  but  a  single 
example,  in  which  the  labia  projected  an  inch  and  a  half  from 

the  surrounding  skin  and  measured 
each  one  inch  and  three-quarters 
transversely.  Supernumerary  devel- 
opment of  the  labia  minora  is  like- 
wise rare.  Both  these  conditions  are 
of  interest  to  the  scientific  student, 
but  call  for  no  gynecological  treat- 
ment. Hypertrophy  of  the  labia 
minora  is  a  more  common  condition. 
It  is  found  normally  in  certain  races, 
as  the  Hottentots,  and  is  occasion- 
ally seen  in  Caucasian  women.  If 
the  hypertrophied  nymphje  are  irri- 
tated and  inflamed,  so  that  locomo- 
tion is  difficult,  or  if  they  interfere 
with  coitus,  they  should  be  excised. 
Ill  Development  of  the  Vulva. — If 
the  internal  genitalia  are  defective, 
the  labia  majora  and  minora  may  be 
small  and  flat,  the  introitus  vaginas  shallow  and  narrow,  the 
mons  veneris  not  prominent  and  poorly  provided  with  hair.  On 
the  other  hand,  with  entire  absence  of  the  vagina  and  uterus,  the 
external  genitalia  may  be  perfectly  developed. 

Hypertrophy  of  the  Clitoris. — The  clitoris  is  sometimes  hy- 
pertrophied to  the  size  of  a  penis.  If  the  overgrown  organ  inter- 
feres with  coitus,  or  if  it  becomes  easily  inflamed  or  irritated  and 
causes  the  individual  decided  discomfort,  the  redundant  portion 
should  be  amputated.  Nothing  is  gained  by  the  amputation  of 
the  clitoris  for  nymphomania  or  for  masturbation.  To  the  dis- 
credit of  gynecology,  this  operation  obtained  considerable  favor 
for  a  time  by  the  enthusiastic  advocacy  of  Baker  Brown  and  a 
few  indiscreet  followers.      It  is  now  known  to  be  useless. 


Fig.    87. — Hypertrophy    of    the 
chtoris. 


Anomalies  of  the  Hymen  73 

Anomalies  of  the  Hymen. — The  hymen  is  normally  a  delicate 
annular  membrane  at  the  outlet  of  the  vagina,  with  a  central  per- 
foration into  which  the  tip  of  the  little  finger  can  be  inserted. 
There  are,  however,  many  variations  of  form  and  orifice.  The 
latter  may  be  crescentic,  with  the  concavity  closely  embracing  the 
urethra.  There  may  be  two  symmetrical  openings  side  by  side 
or  the  orifices  may  be  punctate  and  numerous  (cribriform  h}'men). 
The  edge  of  the  hymen  may  be  dentated,  looking  as  though  it 
had  been  ruptured  by  coitus,  or  it  may  be  apparently  irregularly 
carved  out  of  thickened  tissue  (sculptured  hymen).  The  orifice 
may  be  exceedingly  minute,  or  the  membrane  may  be  imper- 
forate, causing,  after  puberty,  hematocolpos  and  hematometra. 


Fig.  88. — Hypertrophy  of  tlie  clitoris. 

The  hymen  is  occasionally  hypertrophied  ;  it  may  project  beyond 
the  labia  majora  one  to  three  centimeters  (Scanzoni).  It  is  more 
commonly  simply  thickened,  and  opposes  by  its  unnatural 
strength  an  insuperable  barrier,  perhaps,  to  coitus,  but  not  nec- 
essarily to  conception.  In  rare  instances  the  hymen  is  so  elastic 
that  coitus  does  not  rupture  it,  nor  even  the  birth  of  a  fairly 
well  grown  fetus.  An  unruptured  hymen  may  be  seen  in  a  pros- 
titute who  has  plied  her  trade  for  years,  and  Winckel  quotes  a 
case  in  which  a  five  months'  fetus  was  born  without  laceration 
of  the  hymen.  In  a  few  instances  complete  absence  of  the  hymen 
has  been  noted,  and  it  is  occasionally  represented  merely  by  a 
few  ill-developed  papillae. 


74      Anomalies  of  Development  in  Genital  Tract 

Retention  of  Mucus  and  Blood  within  the  Genital  Tract  in 
Consequence  of  Gynatresia  (Hydrometra,  Hematometra;  Hema= 
tocolpos,   Hydrocolpos;   liemelythrometra ;   Hematosalpinx). — 

As  a  result  of  atresia  in  any  portion  of  the  genital  tract,  either 
congenital  or  acquired,  the  secretions  of  the  mucous  membrane 
and  the  blood  at  the  menstrual  periods  can  not  escape,  and  accu- 


Fig.  89. — Uterus  unicornis,  with  absence  of  cervix  and  vagina  ;  enormous  hema- 
tosalpinx, measuring  20  cm.  in  its  longest  diameter  :  ti.  Fundus  of  unicorn  uterus  ; 
f,  fimbriated  extremity  of  tube. 


mulate  from  time  to  time  in  spite  of  a  certain  amount  of  absorp- 
tion that  goes  on  between  the  periods. 

In  atresia  of  the  cervix,  the  mucus  from  the  endometrium  and 
the  blood  of  the  menstrual  periods  after  puberty  accumulate 
steadily,  first  dilating  the  cervical  canal  and  in  time  the  uterine 
cavity,  until  large  quantities  of  blood  may  be  contained  within 
the  womb,  thinning  the  walls  perhaps  to  the  tenuity  of  paper,  or 
possibly  being  accompanied  b}'  an  eccentric  hj^pertrophy  of  the 


Hematometra 


75 


uterus  and  thickening  of  the  waUs.  In  the  course  of  time,  both 
in  congenital  and  acquired  atresia,  there  is  an  accumulation  within 
the  tubes  (hematosalpinx)  as  well  as  within  the  uterine  cavity 
(hematometra).  The  fluid  in  the  tubes  is  derived  not  only  from 
a  regurgitation  of  uterine  fluid,  but  also  from  the  tubal  mucous 
membrane.  Communication  between  the  tube  and  the  uterine 
cavity  may  be  shut  off,  proving  conclusively  the  tubal  origin  of 
the  accumulated  blood.  The  fluid  within  the  uterus  and  tubes  is 
dark  and  thick. 

The  symptoms  of  hematometra  appear  only  after  puberty. 
There  are  at  each  menstrual  epoch  increasing  pains  of  a  cramp- 
like character  and  intense  bearing-down  efforts  without  the 
escape  externally  of  blood.  The  patient  herself  or  her  friends 
commonly  recognize  the  fact  that  there  is  a  mechanical  obstruc- 
tion to  the  escape  of  the  menstrual  fluid.  In  time,  from  irritation 
and  congestion,  an  inflammation 
begins  in  the  pelvis,  and  asso- 
ciated with  the  symptoms  of  re- 
tention of  fluid  within  the  uterus 
there  are  the  symptoms  of  pelvic 
peritonitis.  Suppuration  within 
the  womb  or  within  the  tubes 
may  occur,  converting  the  case 
into  one  of  pyometra  or  pyosal- 
pinx.  Ordinarily  the  suffering  is 
so  extreme  and  the  tumor  of 
accumulated  blood  is  so  well 
marked  within  a  few  years  after 
puberty  that  surgical  interven- 
tion is  required.  But  cases  are 
recorded  of  persistently  recurring 
menstrual  molimina  and  a  steady  accumulation  of  blood  for  more 
than  twenty  years  before  the  patient  was  relieved  by  an  opera- 
tion. It  is  probable  that  the  secreting  mucosa  of  the  genital 
canal  undergoes  a  pressure  atrophy  in  time  and  that  the  quantity 
of  exuded  blood  diminishes  from  month  to  month. 

If  the  point  of  atresia  is  situated  low  in  the  genital  canal,  at 
the  middle  third  or  outlet  of  the  vagina,  the  fluid  accumulates 
first  within  the  vagina  (hematocolpos),  and  only  after  some  time  is 
there  dilatation  of  the  cervix,  and  at  last  of  the  uterine  cavity 
(hemelythrometra),  which  commonly  preserves  for  a  long  period 
an  hour-glass  form  by  the  projection  inward  of  the  internal  os. 
In  examining  such  a  case  the  uterus  may  be  felt  as  a  solid  body 
perched  upon  the  cystic  tumor,  consisting  of  the  dilated  vagina 
and  cervix.      If  the  obstruction  is  an  imperforate  hymen  there 


Fig.    90. — Occlusion    of    the    vagina : 
c2,  b.  Transverse  septum. 


76      Anomalies  of  Development  in  Genital  Tract 

is  in  time  a  bulging  outward  of  the  membrane,  protruding 
between  the  labia.  In  neglected  cases,  or  in  those  in  which 
a  correct  diagnosis    has   not   been    made,  there    is    occasionally 


Fig.  91. — Atresia  of  the  vaginal  outlet. 


Fig.    92. — Atresia   of  lower   third   of 
vagina. 


Fig-  93- — Atresia  of  the  vaginal  orifice  ;  hematocolpos  and  heniatometra  :  v,  Vagina  ; 

oil,  internal  os. 


a  .  spontaneous    evacuation    of   the    fluid    by    a    rupture    at   the 
seat  of  the  atresia.      These  cases  are  very  likely  to  end  unfor- 


Hematocolpos 


11 


tunately;  the  fluid  is  not  freely  evacuated,  and  the  portion  that 
remains  behind  is  extremely  likely  to  become  infected,  the  in- 
fection rapidly  spreading  to  the  tubes  and  thus  to  the  peritoneal 
cavity,  or  to  the  lymphatic  and  venous  channels  of  the  uterine 
wall.  Spontaneous  rupture  may  likewise  occur  into  the  perito- 
neal cavity,  either  by  a  laceration  of  the  tubal  walls  or  by  rupture 
of  the  uterus  above  its  peritoneal  attachment.    This  accident  may 


Fig.  94. — Unilateral  hematocolpos  and  hematometra  (Martin). 


Fig.  95. — Lateral  hematometra. 


be  followed  by  the  rapid  development  of  septic  peritonitis.  The 
author  has  seen  a  rupture  into  the  bladder  of  a  hemelythrometra 
due  to  acquired  atresia  of  the  vagina.  In  cases  of  double  uterus 
and  vagina  it  is  not  uncommon  to  find  atresia  on  one  side,  with  a 
consequent  lateral  hematometra  or  hematocolpos.  Such  cases 
are   not  so  easy  to  recognize   as  those  already  described,  but  a 


78      Anomalies  of  Development  in   Genital  Tract 

careful  examination  should  almost  always  avoid  error.  In  hema- 
tocolpos,  a  cystic  tumor  is  found  occupying  one  side  of  the  vaginal 
canal,  and  a  bimanual  examination  may  reveal  the  body  of  a 
uterus  above  it,  while  on  the  unaffected  side,  evidences  of  duplex 
formation  in  the  womb  may  be  apparent. 

If  the  atresia  affects  one  side  of  the  uterus  only  in  a  case  of 
septate  or  double  womb,  a  cystic  tumor  may  be  detected  directly 
alongside  the  normal  half  of  the  uterus  and  obviously  intimately 
connected  with  it.  A  history  of  periodicity  in  the  pain  caused 
by  accumulated  fluids  coincident  with  the  menstrual  period  is 
also  a  help  in  the  diagnosis.  Finally,  puncture  of  the  obliterated 
half  of  the  cervix  verifies  the  presumptive  diagnosis. 


Fig.  96. — Lateral  pyometra,  evacuated  through  patent  cervical  canal :  e,  r,  Fun- 
dus;./", ,^,  Fallopian  tubes;  /i,  cervical  canal,  dilated;  t,  opening  into  patent  cervi- 
cal canal  ;  a,  external  os. 


The  Treatment  of  Retention  within  the  Genital  Canal  of  Menstrual 
Blood  and  Mucous  Discharge.— Before  undertaking  the  evacuation 
of  retained  fluids  in  the  genital  canal  the  condition  of  the  tubes 
must  be  ascertained  by  a  combined  rectal  and  abdominal  exami- 
nation. If  they  are  distended,  as  they  often  are,  the  safest  plan 
for  the  patient  is  the  performance  of  an  abdominal  section  and  the 
removal  of  the  tubes.  If  there  is  doubt  as  to  the  tubal  condi- 
tion, an  exploratory  abdominal  section  is  indicated.  No  matter 
how  carefully  the  point  of  atresia  is  punctured,  or  how  cautiously 
and  sloAvly  the  fluid  is  evacuated,  or  how  scrupulously  aseptic 
the  operation  may  be,  it  is  impossible  to  insure  the  evacuation 
from  the  tubes  of  the  thick  tarry  blood  they  contain.  Infection 
of  the  tubal  contents  is  very  probable,  and  a  septic  peritonitis  is 
the   result.      The  tubes,  if  they  are   distended  or  diseased,  being 


Hermaphroditism  79 

removed,  the  site  of  the  atresia  may  be  punctured  with  a  trocar, 
the  opening  enlarged  by  bougies  or  by  a  blunt-pointed  bistoury, 
and  the  fluid  in  the  vagina  and  uterus  washed  out  or  mopped 
out  with  pledgets  of  gauze.  It  is  not  difficult  to  empty  the 
uterus  and  vagina  completely,  and  as  they  are  emptied  their 
walls  contract.  The  opening  which  has  been  made  is  maintained 
b}-  a  flap-splitting  operation,  transplantation  of  flaps  from  the 
labia,  the  insertion  of  a  metal  or  glass  tube,  or  repeated  packing. 
If  the  point  of  atresia  is  the  cervix,  repeated  dilatation  of  the 
canal  with  bougies  may  be  required  after  the  opening  is  made. 
It  may  be  preferable  to  amputate  the  cervix  above  the  site  of  the 
atresia,  if  possible,  joining  the  mucous  membrane  of  its  canal  to 
that  of  the  vaginal  vault  by  sutures. 

It  may  appear  in  the  abdominal  section  to  remove  the  tubes 
or  to  investigate  their  condition  that  the  best  course  is  the 
complete  removal  of  the  distended  uterus,  with  the  tubes  (Fig. 
89).  If  the  accumulation  of  fluid  is  due  to  an  imperforate  hymen, 
or  an  atresia  of  the  lower  third  of  the  vagina;  if  there  is 
hematocolpos  and  some  degree  of  hematometra,  but  the  tubes 
are  not  involved,  it  suffices  to  make  a  crucial  incision  in  the 
hymen,  or  a  blunt  dissection  of  the  tissues  obstructing  the 
vaginal  canal,  letting  the  fluid  escape  slowly  at  first,  and  finally 
irrigating  the  genital  canal  through  a  reflux  catheter  with  a  warm 
boracic  acid  solution,  continuing  the  irrigation  until  the  canal  is 
washed  clean.  The  vaginal  canal,  and  the  uterine  cavity,  too,  if 
it  is  dilated,  should  be  packed  with  iodoform  gauze,  thickly 
dusted  with  boracic  acid  powder.  The  packing  is  renewed  every 
twelve  hours,  and  each  time  it  is  replaced  the  genital  canal 
should  again  be  irrigated. 

Hermaphroditism. — A  true  hermaphrodite,  an  individual 
with  functionally  active  glands  of  both  sexes,  provided  with 
excretory  ducts,  has  not  yet  been  discovered,  and  probably 
never  will  be.  In  many  instances  true  hermaphroditism  has  been 
claimed  for  an  individual  or  a  specimen,  but  very  few  indeed  of 
these  descriptions  bear  scientific  criticism.      For  examples  : 

The  case  described  by  Barkow,  in  which  there  was  undoubt- 
edly one  testicle,  without,  however,  a  vas  deferens,  and  another 
body  described  as  an  ovary,  which  histologically  was  made  up 
mainly  of  fat,  connective  tissue,  and  blood-vessels. 

The  case  of  Berthold,  in  which  there  were  a  testicle  in  the 
right  half  of  the  scrotum,  between  the  rectum  and  blad.der  a 
uterus  unicornis,  on  the  right  side  no  adnexa,  but  on  the  left  a 
round  ligament,  tube,  and  "  ovary."  The  last  lacked  the  charac- 
teristic histological  elements  of  a  normal  ovary. 

The  case  of  Banon,  in  which,  on  the  left  of  the  small  uterus, 


8o      Anomalies  of  Development  in  Genital  Tract 

there  were  a  tube  and  an  ovary,  on  the  right  a  testicle  with  vas 
deferens.  The  ovary  again,  in  this  case,  showed  no  Graafian  fol- 
licles ;  it  was  made  up  principally  of  connective  tissue. 

The  case  described  by  Heppner  was  that  of  a  two-months- 
old  child.  The  external  genitals  were  of  the  mascuKne  type. 
The  penis  was  imperforate.  Internally  there  was  an  infantile 
uterus  with  tubes  and  ovaries  on  either  side.      On  each  side,  also. 


Fig-  97- — Hermaphroditismus  bilateralis  :  a,  Glans  penis  ;  h,  corpus  cavernosum 
penis  ;  c,  corpus  cavernosum  of  urogenital  canal  ;  d,  its  bulb  ;  e,  its  anterior  arm  ;  f, 
membranous  portion  of  urogenital  canal ;  h,  prostate  ;  i,  bladder ;  k,  ureters  ;  /,  va- 
gina; ni,  uterus  ;  «^,  fundus  uteri  ;  o,  o,  tubes  ;  p,  p,  their  infundibula  ;  q,  q,  ovaries  ; 
q^,  q' ,  their  ligaments;  r,  right  testicle;  s,  left  testicle  ;  t,  left  parovarium  ;  u,  right 
parovarium  ;  v,  hydatid  of  Morgagni ;  w,  w,  blood-vessels  ;  x,  x,  round  ligaments  ; 
y,  y,  broad  ligaments  ;  *,  muscle-fibers  from  bladder  and  vagina. 


there  was  a  testicle,  separated  from  the  ovaiy  by  the  parovarium. 
While  the  microscopical  examination  demonstrated  the  nature  of 
the  ovaries,  it  could  not  be  demonstrated  clearly  under  the  micro- 
scope that  the  neighboring  glands  were  testicles.  There  may, 
however,  be  imperfectly  developed  glands  of  both  sexes  in  one 
individual.^ 

1  "Ein  Fall  von  Hermaphroditismus,"   G.  Schmorl,  "Virchow's  Archiv,"  Bd. 
cxiii,  p.  229. 


Pseudohermaphroditism  8i 

Friedrich  W.,  aged  twenty-one  years,  art  student  from  Berlin, 
sought  admission  to  the  surgical  clinic  in  Leipsic  for  a 
congenital  defect  of  the  sexual  organs,  which  proved  to  be 
hypospadias.  He  was  operated  upon  and  died.  The  postmor- 
tem examination  resulted  as  follows  :  Face  bearded,  hairs  about 
two  centimeters  long.  Breasts  undeveloped.  Mons  veneris  had  a 
hairy  growth  like  a  female,  ending  abruptly  above.  The  penis, 
freed  from  its  adhesions  by  the  operation,  measured  about  5.5 
centimeters  in  length  on  the  upper  surface  and  had  a  circumference 
of  8  centimeters.  The  glans  was  1.25  centimeters  long.  At 
the  sides  of  the  penis  were  genital  folds  projecting  above  and 
grasping  the  penis  between  them.  Internally  there  was  discov- 
ered an  opening  into  the  urethra  3.5  centimeters  back  of  the  ex- 
ternal orifice,  into  which  a  sound  could  be  passed  for  15  centime- 
ters. Further  dissection  discovered  this  canal  to  be  a  vagina 
and  a  uterus,  the  latter  separated  into  cervix  and  corpus.  On  the 
left  side  the  tube  ran  into  the  inguinal  canal  and  was  continuous 
with  a  body  removed  from  the  groin  at  the  operation,  thought  at 
the  time  to  be  a  testicle,  but  which  was  found  to  be  mainly  the 
distended  and  distorted  fimbriated  extremity  of  a  Fallopian  tube. 
Microscopical  examination  of  this  body  showed  in  it  the  remains 
of  a  sexual  gland  having  all  the  histological  characteristics  of  a 
fetal  ovary  without  ovules.  On  the  right  side  there  were  a  round 
ligament,  tube,  and  ligament  analogous  to  that  of  the  ovary,  all 
running  down  to  the  sexual  gland  in  the  right  scrotal  sac,  which 
the  miscroscope  showed  to  be  a  testicle.  There  Avere  no  spermat- 
ozoa, nor  was  there  a  vas  deferens.  It  really  seems  that  this 
might  be  called  an  example  of  true  lateral  hermaphroditism. 

Pseudohermaphroditism. — Klebs  classifies  pseudohermaph- 
rodites in  the  following  manner: 

Pseudohermaphrodites  with  double  sexual  formation  of  the 
external  genitals,  but  with  unisexual  development  of  the  repro- 
ductive glands  (ovaries,  testicles). 

I.   Male  pseudohermaphrodites  (with  testicles). 

1.  Internal  pseudohermaphrodites.  Development  of  uterus 
masculinus. 

2.  External  pseudohermaphrodites.  External  genitals  ap- 
proach female  type ;  feminine  appearance  and  build. 

3.  Complete  pseudohermaphrodites  (internal  and  external). 
Uterus  masculinus  with  tubes.  Separate  efferent  canals  for 
bladder  and  uterus. 

II.  Female  pseudohermaphrodites  (with  ovaries).  Persis- 
tence of  male  sexual  parts. 

I.  Internal  hermaphrodites.  Formation  of  vas  deferens  and 
tubes. 

6 


82      Anomalies  of  Development  in  Genital  Tract 

2.  External  hermaphrodites.     Approach  of  external  genitals 
to  male  type. 

3.  Complete  hermaphrodites  (external  and  internal).      Mas- 


Fig.  98. 


-Masculine   pseudohermaphroditism    (wax  model ;   Hodge  collection.  Uni- 
versity of  Pennsylvania). 


Fig-  99- — Same  as  figure  98,  in  profile,  showing  uterus. 


culine   formation  of  the  external   genitals  and  of  a  part  of  the 
sexual  tract. 

As  may  be  seen  in  the  classification,  pseudohermaphrodites 


Pseudohermaphroditism 


83 


have  the  glands  of  one  sex,  but  other  sexual  parts  either  inter- 
mediate or  mixed.  They  are  in  the  vast  majority  of  cases  of  the 
masculine  sex,  although  this  may  be  difficult  to  determine  dur- 
ing life.  Numerous  instances  are  recorded  of  mistakes  as  to  sex 
which  continued  throughout  a  great  part   or  the  whole  of  life. 


Fig.    100. — Masculine    pseudohermaphroditism  :     va.  Vagina  ;    v,  bladder  ;    r,  rec- 
tum ;  /,  penis  ;  s,  symphysis  ;  t,  testicle. 


Fig.    loi. — Masculine  pseudohermaphroditism  with  vagina,   uterus  masculinus,  and 
tubes.     The  vagina  empties  into  the  urethra. 


The  author  has  seen  an  individual  don  his  first  trousers  at  the 
age  of  nineteen.  He  had  been  brought  up  as  a  girl,  until  his 
beard  began  to  grow  and  he  began  to  manifest  sexual  inclina- 
tions toward  his  female  companions. 


84      Anomalies  of  Development  in  Genital  Tract 

A  masculine  pseudohermaphrodite  has  in  a  number  of  in- 
stances married  as  a  woman,  and  learned  his  true  sex  only  on 
consulting  a  physician  for  sterility.  It  is  safer,  in  cases  of  doubt, 
to  regard  the  sex  as  masculine  and  to  clothe  and  educate  the 
individual  as  a  male.^ 

There  are  many  degrees  of  masculine  pseudohermaphro- 
ditism, from  a  simple  enlargement  of  the  vesicula  prostatica, 
without  abnormality  of  the  external  genitals,  to  the  full  develop- 
ment of  a  uterus  masculinus,  divided  into  corporeal  and  cervical 


Fig.      102.  —  Pseudohermaphroditism 

proper.      External  organs  of  Louise  B 

(man)  :  g,   Glans;    b,  frenum  ;  ov,   vulvar 
orifice ;     hy,    hymen ;     f,    fourchet  ;     //, 
jnymphse;  gl,  labia   majora ;    mu,    meatus 
urinarius. 


Fig.    103. — Pseudohermaphro- 
ditism   proper.       External    genitals 

of  Julia  D (man).      Feminine 

appearance  of  the  parts  with  the 
penis  raised  and  the  thighs  sepa- 
rated :  h,  Frenum  ;  mu,  meatus  ;  ov, 
vulvar  orifice. 


portions,  with  perfect  tubes  and  a  vagina  opening  externally  into 
a  urogenital  cleft. ^  In  the  latter  case  the  peilis  is  rudimentary 
and  there  is  hypospadias ;  the  urethra  opens  by  a  separate  canal 
at  the  urogenital  cleft;  there  is  a  rudimentary  development  of  the 
scrotal  halves,  and  the  testicles  may  be  in  the  abdominal  cavity. 

1  A  male  pseudohermaphrodite,  with  a  penis,  scrotum,  and  testicles,  but  with  a 
vagina  and  uterus,  having  a  feminine  type  of  body,  told  the  author  that  he  was  un- 
happy in  his  dress  and  occupation  as  a  male.  He  thought  it  would  have  been  wiser 
had  he  been  educated  and  clothed  as  a  female. 

2  Engelhardt  reports  a  case  of  carcinoma  of  the  uterus  in  a  male  pseudoher- 
maphrodite.     "  Monatsschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  xii,  H.  6. 


Pseudohermaphroditism 


85 


Fig.      104. — Partial     pseu- 
dohermaphroditism, with    hyper- 
trophy of  clitoris  (Pozzi). 


Fig.    105. — Masculine   pseudohermaphroditism 
(Bonnet  and  Petit). 


Fig.  106. 


Fig.  107. 


Figs.  106  and  107. — Carl  Lohmann,  masculine  pseudohermaphrodite,  who  lived  for 
forty-six  years  as  a  female.      He  then  assumed  male  attire  and  married  as  a  man. 


86      Anomalies  of  Development  in  Genital  Tract 


The  vasa  deferentia  empty  usually  in  the  urethra,  sometimes  in 
the  urogenital  cleft,  and  rarely  in  the  cavity  of  the  vesicula.  The 
character  of  the  body  closely  approaches  the  female  type  in  well- 
marked  cases  of  masculine  pseudohermaphroditism.  The  hair 
on  the  head  grows  long,  the  beard  is  very  scanty  or  fails  to  ap- 
pear, the  breasts  are  large  and  sometimes  contain  secretion,  the 
waist  is  small,  and  the  hips  are  broad.  A  regular  monthly  dis- 
charge of  blood  and  mucus  from  the  genitalia  or  the  urethra  has 
been  noted  in  several  instances.      It   is  not  strange  that  such 

creatures  should  be  regarded 
as  females,  for  the  only  true 
mark  of  their  sex  may  not  be 
discoverable  till  after  death. 
The  best  proofs  of  sex  during 
life  are  afforded  by  the  pres- 
ence of  spermatic  particles  in 
the  discharge  accompanying 
sexual  excitement  in  the  male 
and  by  impregnation  in  the 
female.  In  intermediate  grades 
the  external  genitals  may  not 
be  much  affected,  and  the 
uterus  masculinus  and  vagina 
may  open  into  the  urethral 
canal  of  a  fairly  well  formed 
penis.  The  scrotum  may  show 
various  grades  of  develop- 
ment :  one  half  may  be  pretty 
well  formed  and  contain  a 
testicle,  while  the  other  is 
rudimentary^  and  empty.  The 
testicle  in  such  a  case  may  be 
detected  in  the  inguinal  canal 
or  may  be  altogether  in  the 
abdomen.  However  doubtful 
might  be  the  sex  of  a  mascu- 
line pseudohermaphrodite  during  life,  an  examination  of  the  pelvic 
cavity  after  death  should  settle  the  matter  definitely,  and  yet  mis- 
takes have  been  made  in  the  description  of  postmortem  specimens. 
Feminine  pseudohermaphroditism  is  rare,  and  reported  cases 
should  always  be  regarded  with  a  suspicion  that  the  individual  is 
really  a  man.  A  hypertrophied  clitoris,  perhaps  a  rudimentary 
vagina,  ovaries  prolapsed  into  the  labia,  the  formation  of  the 
scrotum,  and  the  existence  of  vasa  deferentia  are  the  character- 
istics of  this  class. 


Fig.  io8. — Feminine  pseudohermaph- 
roditism. The  right  labium  contained  an 
ovary  ( Fehling). 


Pseudohermaphroditism 


87 


The  following-  remarkable  case  was  reported  to  the  "New 
York  Medical  Journal,"  November  22,  1890,  by  Dr.  C.  W. 
Fitch,  at  one  time  in  charge  of  the  sanitary  service  of  Salvador, 
Central  America : 

"J.  H.  A.,  a  house  servant,  of  masculine  features  and  move- 
ments ;  aged  twenty-eight  years  ;  height,  five  feet  seven  inches  ; 
weight,  one  hundred  and  thirty-nine  pounds ;  was  arrested  by  the 
police  for  violating  the  law  governing  prostitution.  On  examina- 
tion, both  female  and  male  organs  of  generation  were  found  in  a 


Fig.  109. — Feminine  pseudohermaphroditism. 


remarkably  well  developed  condition.  The  labia  majora  were 
of  normal  size,  but  flattened  on  their  anterior  surface.  The  labia 
minora  and  hymen  were  absent.  The  vagina  was  capacious, 
four  and  one-half  inches  long  anteriorly  and  six  inches  poste- 
riorly. The  OS  uteri  was  torn  on  the  left  side.  There  was  pro- 
fuse leukorrhea.  Seven  years  before  she  had  given  birth  to  a 
normal  female  infant.  In  place  of  the  clitoris  there  was  a  penis, 
which,  when  in  erection,  measured  five  inches  and  a  quarter  long 
by  three  and  five -eighths  inches   in  circumference.      The  glans 


88      Anomalies  of  Development  in  Genital  Tract 

penis  and  the  urethra  were  perfectly  formed.  The  scrotum, 
which  was  two  and  one-eighth  inches  long,  contained  two  testi- 
cles (?)  about  an  inch  in  length  and  two  inches  and  a  half  in  cir- 
cumference. The  mons  veneris  was  sparsely  covered  with  short, 
straight,  black  hair.  Both  sets  of  organs  were  perfect  in  their 
functions,  semen  being  ejected  from  the  penis  (?),  and  the  ovaries 
being  capable  of  producing  eggs.  Scanty  menstruation  occurred 
every  three  weeks  and  lasted  but  two  days.  Sexual  gratification 
was  said  to  be  equally  distributed  between  the  two  sets  of 
organs."  Stripped  of  inaccuracies,  this  is  doubtless  a  description 
of  a  remarkable  example  of  pseudohermaphroditismus  feminus. 
It  seems  to  be  a  well-established  fact  that  the  external 
appearance  of  a  masculine  pseudohermaphrodite  corresponds 
with  the  type  of  the  external  genitals.     The  more  closely  they 


Fig.  no. — Feminine  pseudohermaphroditism.      Same  case  as  figure  109 


approach  the  female  form,  the  more  feminine  is  his  appearance. 
This  is  well  illustrated  in  the  case  of  Carl  Lohmann,  and,  nega- 
tively, in  the  case  reported  by  Bonnet  and  Petit,  of  a  man  with 
pseudoscrotal  hypospadias,  who  was  educated  and  clothed  as 
a  girl,  but  who  had  nothing  feminine  in  his  appearance  except 
long  hair  and  his  dresses.  He  was  in  the  habit  of  copulating 
with  his  female  companions,  and  acquired  in  time  a  chancre. 
In  female  hermaphrodites  this  rule  does  not  always  hold  good  ; 
the  feminine  appearance  may  be  retained  in  spite  of  a  close 
approximation  of  the  external  genitalia  to  the  male  type.  The 
individual  represented  in  figure  109  claimed  to  be,  and  was 
regarded  as,  a  woman,  but  may  possibly  have  been  a  male  pseudo- 
hermaphrodite. 


PART  III. 

DISEASES  AND  INJURIES  OF  THE  VULVA;  COCCYGODYNIA. 

The  vulva  is  a  generic  name  applied  to  the  labia  majora,  labia 
minora,  clitoris,  vestibule,  fourchet,  and  fossa  navicularis.  The 
vulvovaginal  glands,  the  bulbs  of  the  vestibule,  the  external  uri- 


fbss« 


Fig.  III. — Diagram  of  the  genitalia  (Dickinson). 


nary  meatus,  and  the  urethral   glands  are  structures   belonging 
anatomically  to  the  vulva. 


90 


The  Vulva 


The  mons  veneris  is  a  flat  protuberance  over  the  symphysis 
pubis,  consisting  of  fat  and  connective  tissue  covered  by  a 
tough  skin  clothed  with  coarse  hair.  In  females  the  upper  bor- 
der of  the  hairy  region  is  a  horizontal  line;  in  males  the  hair 
rises  in  a  triangular  shape  to  a  point  upon  the  median  line  of  the 
abdominal  wall. 

The  labia  majora  are  folds  of  skin  containing  fat,  connective 
tissue,  and  involuntary  muscle-fibers,  continuous  with  the  mons 
veneris  and  uniting  below  an  inch  in  front  of  the  anus.  They 
surround  the  urogenital  fissure.  Their  points  of  junction  above 
and  below  are   called   the  anterior  and  posterior  commissures. 


Fig.  112. — Normal  vulva  in  a  virgin. 


Just  within  the  latter  there  is  a  crescentic  transverse  fold  of  skin, 
called  the  fourchet.  Between  the  fourchet  and  the  base  of  the 
hymen  is  the  fossa  navicularis. 

The  Labia  Minora,  or  Nymphas. — Just  below  the  anterior 
commissure  of  the  labia  majora  the  nymphas  begin  on  each  side 
as  two  leaflets  of  delicate  skin;  one,  the  upper,  with  its  fellow  of 
the  other  side,  constituting  the  prepuce  of  the  clitoris ;  the  lower 
leaflet,  with  its  other  half,  forming  the  frenum  of  the  prepuce. 
These  two  leaflets  on  each  side  unite  below  and  to  the  outer 
side  of  the  clitoris,  to  form  the  labium  minus,  which  runs 
downward  to  merge  into  the  labium  majus  at  about  its  middle 
or  lower  third.     The  labia  minora  are  often  asymmetrical.    They 


The  Vestibule 


91 


lie  apposed  to  each  other  in  the  middle  line,  completely  covered 
by  the  labia  majora.  They  vary  much  in  size.  The  covering 
of  the  nymph^e  is  in  a  transition  stage  between  mucous  mem- 
brane and  skin.  It  merges  on  its  outer  side  into  the  dehcate 
skin  of  the  inner  surface  of  the  labia  majora,  and  on  its  inner 
side  into  the   mucous   membrane  of  the  vestibule.      The  venous 


Fig.  113. — Normal  vulva  (Deaver). 


Spaces  and  the  unstriped  muscular  fibers  in  the  nymphae  resemble 
the  structure  of  erectile  tissue. 

The  vestibule  is  the  space  between  the  clitoris,  nymphs, 
and  vaginal  entrance.  It  is  pierced  in  its  mid-line  by  the  urethral 
orifice — the  external  meatus.  The  bulbs  of  the  vestibule  are 
two  masses  of  venous  plexuses  about  an  inch  long,  lying  along 
the  sides  of  the  vestibule  below  the  clitoris  and  within  the 
nymphae.     They  are  the  homologues  of  the  corpora  spongiosa 


92  The  Vulva 

in  the  male.  In  sexual  excitement,  by  muscular  compression  of 
their  efferent  vessels,  they  becomie  turgid  and  erect. 

The  clitoris  has  the  structure  and  anatomical  features  of  the 
penis,  but  in  miniature,  and  modified  by  the  cleft  below,  the  ab- 
sence of  the  urethra,  and  the  separation  of  the  spongy  bodies 
into  the  bulbs  of  the  vestibule.  The  cavernous  bodies  of  the 
clitoris  are  erectile.  The  glans  of  the  clitoris  is  surrounded  at 
its  base  by  sebaceous  follicles  secreting  a  smegma,  which,  if  con- 
fined b)'  preputial  adhesions,  may  cause  irritation  by  its  decom- 
position. 

Bartholin's  glands,  or  the  vulvovaginal  glands,  are  muco- 
serous,  racemose  glands  about  a  third  of  an  inch  in  diameter, 
lying  under  the  mucous  membrane  of  the  lateral  vaginal  Avails 
and  emptying  by  long,  slender  ducts  on  the  under  surfaces  of  the 
labia  majora  just  outside  the  vaginal  entrance. 

The  Hymen. — The  crescentic  septum,  occluding  usually  the 
posterior  portion  of  the  vaginal  entrance,  with  the  concavity  of  its 
opening  directed  upward,  but  presenting  often  an  annular,  crib- 
riform, cordiform,  crenelated,  or  cleft  appearance,  is  a  fold  of  mu- 
cous membrane  reinforced  by  fibrous  tissue,  usually  ruptured  with 
ease,  but  occasionally  so  firm  and  unelastic  that  it  even  resists 
the  impact  of  the  descending  head  in  labor.  The  hymen  is  torn 
at  the  first  coitus,  sometimes  by  gynecological  examinations,  or 
by  masturbation.  It  is  partially  destroyed  in  labor,  the  remnants 
persisting  as  isolated  protuberances  around  the  vaginal  orifice — 
the  carunculae  myrtiformes. 

The  sensory  nerve=supply  of  the  vulva  is  derived  from  the 
pudic  nerve  or  its  two  terminal  branches,  the  dorsal  nerve  of  the 
clitoris,  and  the  perineal  nerves,  the  inferior  pudendal,  the  genito- 
crural,  and  the  ilio-inguinal.  The  perineal  branches  of  the  pudic 
are  given  off  at  the  outer  upper  edge  of  the  ischiorectal  fossa. 
The  nerve  of  the  dorsum  of  the  clitoris,  one  of  the  terminal 
branches  of  the  pudic,  lies  to  the  outer  side  of  the  pudic  artery 
and  runs  alongside  the  inner  surface  of  the  ascending  ramus  of 
the  ischium,  under  the  inferior  layer  of  the  triangular  ligament. 
The  inferior  pudendal  nerve  crosses  the  ascending  ramus  of  the 
ischium  an  inch  above  the  tuber  ischii,  running  upward  and 
inward  to  the  labium  ;  the  genital  branch  of  the  genitocrural 
and  the  ilio-inguinal  descend  to  the  labium  from  the  external 
inguinal  ring. 

Vulvitis. — The  tissues  of  the  vulva  are  covered  by  skin  and 
mucous  membrane  ;  these  coverings  are  subject  to  the  same 
inflammations  as  in  other  parts  of  the  body.  Eczema,  herpes, 
acne  (follicular  vulvitis),  erysipelas,  thrush,  diphtheria,  strep- 
tococcic infection,  furuncles,  need  present  no  difficulties  in  diag- 


PLATE  1. 


Vulvitis 


93 


nosis  and  require  the  same  treatment  as  elsewhere.  An  acute 
inflammation  of  the  vulva  depends  in  more  than  three-quarters  of 
the  cases  upon  gonorrheal  infection,  though  it  may  have  its  origin 
in  uncleanliness,  irritating  discharges  from  the  vagina,  as  in  can- 
cer, vesicovaginal  fistula,  or  senile  leukorrhea,  the  decomposition 
of  diabetic  urine,  seat-worms,  the  infectious  discharges  from  the 
bowels  in  t\'phoid  fever  and  dysentery,  thrush,  traumatism,  the 
mechanical  irritation  of  violent,  too  frequently  repeated  coitus  and 


Fig.  114. — Dissection  of  the  vulva,  showing  nerves  and  blood-vessels.  On  the 
■woman's  right  are  the  inferior  pudendal  and  the  superficial  perineal  branch  of  the 
pudic  ;  on  the  left,  the  inferior  layer  of  the  triangular  ligament  being  removed,  are 
shown  the  two  terminal  branches  of  the  pudic  nerve,  on  either  side  of  the  pudic 
artery  (Deaver). 


masturbation,  or  ungratified  sexual  desire  if  the  woman  is  mated 
with  an  impotent  man. 

In  gonorrheal  vulvitis  the  parts  are  covered  with  a  profuse 
mucopurulent  discharge,  the  skin  is  reddened,  the  mucous  mem- 
brane is  a   deep   scarlet   in    color.      The   patient  suffers   pain  in 


94 


Diseases  of  the  Vulva 


walking-  and  complains  of  burning  on  micturition.  The  acute 
stage  rapidly  subsides  from  the  surface  of  the  vulva,  but  the 
orifice  of  the  urethra  remains  reddened  and  angry  in  appearance, 
a  drop  of  pus  may  be  squeezed  out  of  it  by  passing  the  tip  of 
the  forefinger  along  its  course  from  within  outward,  and  two 
reddened  spots  may  be  seen  where  the  ducts  of  the  vulvovaginal 
glands  open  without  the  hymen  and  to  either  side  of  the  vaginal 
entrance  (gonorrheal  macules).  The  mucous  membrane  of  the 
inner  surfaces    of    the   labia  minora  and   of   the  vestibule  may 


Fig.  115. — Streptococcic  infection  of  the  vulva. 


exhibit  areas  of  intense  congestion  and  inflammation  persisting^ 
for  months  and  years  in  spite  of  treatment. 

In  vulvitis  from  irritation  and  not  from  infection,  the  labia 
minora  are  hypertrophied,  the  mucosa  is  reddened,  but  has  not 
the  angry  appearance  of  gonorrhea,  the  sebaceous  glands  of  the 
labia  minora  are  much  enlarged,  and  the  papillae  of  the  vestibular 
mucous  membrane  project  in  an  acuminate  form  that  suggests 
condylomata,  but  they  are  never  branched  and  they  never  extend 


PLATE  2. 


o  ^ 


£  3 


o 

g 

3 

rt 

5 

s 

M 

C3 

"x; 

IS 

^ 

•^ 

c 

X 

^ 

'5fl 

1) 

d 

OS 

> 

1) 

a; 

0 

■^ 

> 

C 

3 

C 
c 
o 

> 

(D 

z' 

tiX)j3 

CJ 

s 

o 

i_ 

TS 

r^ 

0 

:/; 

<D 

^ 

o 

3 

u 

3 

CJ     r,5       l3 


Vulvitis  95 

to  the  skin  surfaces.  They  are  sometimes  so  extremely  sensi- 
tive that  they  are  probably  neuromatous. 

Treatment. — In  treating  vulvitis  the  cause  must  always  be 
ascertained  and  the  treatment  directed  to  its  removal.  A  cardi- 
nal principle  in  the  treatment,  whatever  the  cause,  is  a  thorough 
cleansing  of  the  parts  twice  dail}-  with  pledgets  of  cotton  and 
warm  water,  to  which  a  small  quantity  of  tincture  of  green  soap 
is  added.  In  gonorrhea,  easily  recognizable  by  the  symptoms 
described  or  demonstrable  as  a  rule  by  the  presence  of  the  gon- 
ococcus,  the  vagina  should  be  douched  twice  daily  with  perman- 
ganate solution  (saturated  solution,  f5j  to  Oij  of  water).  Tam- 
pons in  the  vagina  saturated  with  arg}'rol  solution,  5  per  cent, 
followed  by  a  lamb's-wool  tampon  dusted  with  tannic  acid  or 
saturated  with  boroghxerid,  should  be  inserted  after  the  douche. 
If  possible,  the  patient  should  be  confined  to  bed,  the  diet  should 
be  light,  large  quantities  of  water  should  be  drunk,  and  salol  or 
urotropin  should  be  administered  internally  for  their  antiseptic 
action  on  the  urethra.  When  the  acute  stage  has  passed,  astrin- 
gent vaginal  douches  (zinc  sulphate,  5ss,  powdered  alum,  5j  to 
Oij  of  water)  and  a  dusting-powder  externally  (borated  talcum 
powder)  should  be  used.  If  the  pain  in  the  acute  stage  is  severe, 
hot  fomentations  of  the  fluid  extract  of  witch  hazel  give  relief. 

In  the  non-gonorrheal  forms  of  vulvitis  or  in  chronic  inflam- 
mation which  may  have  had  its  origin  in  gonorrhea,  astringent 
and  antiseptic  applications  are  called  for :  Solutions  of  nitrate  of 
silver,  gr.  x-5j  to  f5J  of  water;  Monsel's  solution,  f5j  to  fSj 
of  glycerin ;  equal  parts  glycerin  and  carbolic  acid  ;  formalin 
solution,  as  strong  as  i  per  cent;  protargol  or  argyrol  solution, 
5  to  50  per  cent.;  glycerole  of  tannin,  iodin  and  glycerin,  or  the 
Churchill  tincture  may  all  be  tried  with  more  or  less  success. 
In  the  worst  cases  the  excision  of  the  mucous  membrane  around 
the  urinary  meatus  in  the  vestibule  and  on  the  inner  surfaces  of 
the  labia  minora  may  be  tried,  but  even  then  the  disease  may 
return  and  persist  for  years.  A  case  under  the  author's  obser- 
vation persisted  in  spite  of  every  treatment,  including  excision, 
and  yielded,  after  some  three  years,  more  to  the  effects  of  time, 
apparently,  than  to  the  remedies  emplo}'ed. 

Tlie  vulvitis  associated  with  senile  leukorrhea  is  easily  cured  by 
inserting  in  the  vagina  at  bedtime  a  vaginal  suppository  containing 
the  milder  antiseptics  (thyme,  eucalyptol,  etc.),  with  glycerin  as  a 
base,  followed  in  the  morning  by  a  boracic  acid  douche,  oj  to  Oij. 
A  napkin  must  be  worn  at  night,  as  the  vaginal  suppository  melts 
and  gives  rise  itself  to  a  discharge.  If  the  vulva  is  irritated  by  dia- 
betic urine,  by  the  constant  maceration  associated  with  a  vesico- 
vaginal fistula,  or  by  the  discharges  of  cancer,  it  may  be  protected 


96 


Diseases  of  the  Vulva 


by  an  ointment  of  boracic  acid,  5j,  ung.  aq.  rosae,  5J,  or  equal 
parts  of  subnitrate  of  bismuth  and  castor  oil.  Thrush  of  the 
vulva  is  cured  quickly  by  a  boracic  acid  wash. 

As  a  result  of  gonorrhea,  or  possibly  in  consequence  of 
streptococcus  or  staphylococcus  infection,  the  vulvovaginal  glands 
may  be  inflamed  and  may  suppurate.  A  vulvovaginal  abscess 
is  usually  unilateral.  The  pain  is  severe,  walking  is  difficult  or 
impossible,  and  there  may  be  well-marked  general  symptoms, 
the  patient  feeling  quite  ill.  The  appearance  of  an  abscess  in 
Bartholin's  gland  is  distinctive.  One  labium  is  much  distended, 
the  vulva  is  asymmetrical,  and  if  the  gland  is  caught  between  the 


Fig.  Il6. — Abscess  of  vulvovaginal  gland. 


forefinger  in  the  vagina  and  the  thumb  externally,  its  enlarge- 
ment is  easily  felt,  and  the  fluid  contents  are  appreciable.  Pres- 
sure on  the  gland  may  result  in  a  drop  of  pus  oozing  out  of  the 
duct,  but  often  the  duct  is  occluded.  The  most  satisfactory 
treatment  of  a  vulvovaginal  abscess  is  the  removal  of  the  whole 
gland,  which  can  easily  be  dissected  out.  If  possible  to  preserve 
it,  the  sac-wall  should  not  be  ruptured  or  cut,  but  as  the  finger- 
like process  running  up  the  vaginal  wall  is  cut  across  to  free  the 
gland,  pus  usually  escapes.  The  cavity  should  be  thoroughly 
cleansed  by  a  sublimate  solution,  i  :  looo,  and  the  tissues  approxi- 
mated  by  interrupted  sutures  of   silkworm-gut,   a  drain   in    the 


Vulvitis 


97 


shape  of  a  few  strands  of  silkwonn-gut  being  laid  the  whole 
length  of  the  wound  under  the  stitches  and  emerging  at  both 
ends.  If  one  is  content  with  a  mere  opening  of  the  abscess  at  the 
junction  of  skin  and  mucous  membrane  on  the  internal  surface  of 
the  labium,  even  if  the  cavity  is  curetted,  cauterized,  and  packed, 
the  patient  may  expect  to  be  annoyed  by  the  recurrence  of  the 
abscess  o\^er  a  period  of  years  if  she  catches  cold,  has  pelvic  con- 
gestion from  an\^  cause,  or  becomes  pregnant.  If  the  gland  does 
not  refill  with  pus  or  mucus,  a  persistent  fistula  at  the  site  of  the 
incision  or  at  the  point  of  spontaneous  rupture  may  discharge  a 


Fig.  117. — Pointed  condylomata  of  the  vulva. 


thin  mucopurulent  fluid  for  months.  In  chronic  inflammation  of 
the  vulvovaginal  gland  concretions  of  a  chalky  character  may 
develop  as  large  as  an  eighth  of  an  inch  in  diameter.  ^ 

In  chronic  infection  of  the  gland,  without  distention  and  sup- 
puration, with  the  orifice  of  the  duct  reddened  (gonorrheal 
macule),  it  may  suffice  to  inject  a  few  drops  of  pure  ichthyol  or  of 
a  50  per  cent,  argyrol  solution  into  the  duct  with  a  blunt- 
pointed  hypodermic  syringe. 

Another  disagreeable  consequence  of  gonorrhea  is  the  de- 
velopment, in  a  small  proportion  of   cases,  of  venereal  warts  or 

^  Scott,  "Amer.  Jour.  Med.  Sci.,"  Oct.,  1S85. 
7 


98 


Diseases  of  the  Vulva 


pointed  condylomata  on  the  labia  and  the  perineum.  Mere  un- 
cleanliness  without  gonorrheal  infection  is  occasionally  respon- 
sible for  the  condylomata,  and  they  sometimes  appear  in  women 
of  the  upper  classes  whose  personal  hygiene  is  beyond  reproach 
and  in  whom  it  is  impossible  to  demonstrate  a  specific  infec- 
tion. The  growths  are  branched  papillomata,  perfectly  distinc- 
tive in  appearance.  They  may  occur  as  isolated  spurs  or  in 
small  patches.  Huge  warty  masses,  usually  pedunculated,  may 
develop  as  a  consequence  of  the  congestion  and  nutritive  stimulus 


Fig.  Ii8. — Single  spurs  of  condyloma  on  the  vulva  with  a  mass  around  the  anus. 


of  pregnancy.  There  is  quite  a  profuse  serous  secretion,  which 
keeps  the  growth  partially  macerated  and  irritates  the  surround- 
ing skin.  The  most  satisfactory  treatment  is  the  excision  of  the 
growths  by  an  oval  incision  in  the  sound  skin  around  their  bases. 
Bleeding  vessels  must  be  ligated  with  catgut  and  the  wound 
clcsed  with  a  running  or  interrupted  catgut  suture.  Single  spurs 
may  be  destroyed  by  puncture  with  the  electrocautery  point, 
after  cocainization. 


Gancrrene  of  the  Vulva 


99 


The  labia  may  be  the  seat  of  suppuration  (^phlegmon)  from 
infection  following  an  abscess  in  Bartholin's  gland  or  an  injury. 
The  phlegmon  is  treated  by  the  ordinary  surgical  procedures — 
free  incisions,  drainage,  irrigation,  and,  if  necessary,  curetment 
or  excision  of  the  diseased  area. 


Fig.  119. — Masses  of  pointed  condylomata  of  the  vulva. 


Fig.  120. — Agglutinated  labia  in  infant:   i,  Before  separation;  2,  afterward. 


Gangrene  of  the  vulva  (noma)  is  rarely  seen  in  young 
children  reduced  in  strength  by  an  adynamic  disease  or  by  very 
unfavorable  hygienic  conditions.     A  whitish  vesicle  first  appears 


lOO  Diseases  of  the  Vulva 

in  the  labium,  which  rapidly  becomes  gangrenous.  The  treat- 
ment consists  of  stimulation  and  support,  with  excision  of  the 
diseased  area. 

In  infants  less  than  a  year  old  inflammation  of  the  inner 
surfaces  of  the  labia,  often  from  gonorrhea,  possibly  from  the 
irritation  of  rectal  discharges,  may  result  in  superficial  ulcer- 
ation, the  formation  of  granulation  tissue,  and  the  agghitinatioii 
of  the  closely  apposed  labia.  There  is  always  a  sinus  left,  some- 
times anterior!}',  sometimes  posteriorly,  or  both.  If  the  opening 
is  near  the  anterior  commissure  the  urine  collects  behind  the 
agglutinated  labia  and  causes  intense  irritation,  which  attracts  the 
attention  of  the  child's  caretaker.  If  the  opening  is  posterior, 
the  urine  escapes  freely  and  the  agglutination  may  be  over- 
looked.    It  has  persisted  to  adult  life  (Rausching,  Saenger). 

The  union  of  the  labia  minora  or  the  labia  majora  is  so  deli- 
cate that  they  may  be  separated  as  a  rule  by  a  small  blunt  instru- 
ment, such  as  a  probe  or  a  grooved  director.  The  separation  may 
be  maintained  by  pulling  the  labia  apart  at  the  daily  bath,  by  a 
light  gauze  pack  in  the  vulvar  orifice,  or,  if  necessary,  by  a  few 
interrupted  catgut  sutures  approximating  the  skin  and  mucous 
membrane  over  the  abraded  surfaces. 

Pruritus  Vulvas. — Intense  itching  of  the  vulvais  usually  symp- 
tomatic. It  is  due  to  a  local  cause  of  irritation,  as  pediculi,  scabies, 
ringworm,  thrush  fungus  ;  to  trichiasis  (ingrowing  hairs)  or  to  a 
localized  dermatitis,  as  eczema  or  follicular  vulvitis  ;  to  irritating 
discharges  from  cancer  of  the  cervix,  senile  vaginitis,  myoma  of  the 
uterus,  chronic  endometritis;  to  excessive  sexual  indulgence  or 
masturbation ;  above  all,  to  the  decomposition  of  the  urine 
of  diabetes  mellitus.  It  may  be  a  reflex  symptom  depen- 
dent upon  seat-worms,  hemorrhoids,  fissure  in  ano,  disease  of 
the  uterus  and  its  appendages.  It  may  be  a  localized  expres- 
sion of  a  gouty  or  rheumatic  diathesis,  or  of  an  intestinal  toxemia 
due  to  shell  fish,  alcohol,  or  other  food-stuffs  to  which  there  is  an 
individual  idiosyncrasy.  The  prolonged  use  of  certain  drugs,  as 
quinin,  has  been  a  cause. 

In  rare  instances  the  pruritus  may  be  idiopathic.  It  is  a 
neurosis.  After  a  time  changes  occur  in  the  affected  area  due 
apparently  to  constant  scratching.  There  is  a  thickening  of  the 
corium  by  connective-tissue  hyperplasia  ;  the  skin  is  thickened, 
leather-like  in  consistency,  and  unnaturally  white  in  color,  with 
excoriations  here  and  there  caused  by  the  patient's  finger-nails. 
It  was  this  condition  which  suggested  to  Saenger  the  name 
vulvitis  pruriginosa.  Webster^  found  on  microscopical  study  a 
steadily  progressing  fibrosis  of  the   nerves  and  nerve-endings  of 

'  J.  C.  Webster,  "  Edinb.  Med.  Jour.,"  July,  1891. 


PLATE  3. 


Pruritus  vulva;  of  twenty  years'  duration  ;  kraurosis  vulvae  ;  epithelioma  of  the  clitoris. 


Pruritus  Vulvae 


lOI 


the  nymphae  and  clitoris,  but  Schroeder  and  others  have  failed  to 
find  any  anatomical  alteration  in  the  skin  removed.  The  region 
affected  is  chiefly  the  inner  surfaces  of  the  labia  majora,  the  labia 
minora,  and  the  clitoris  ;  occasionally  the  itching  extends  to  the 
mons  veneris,  the  anus,  and  the  inner  surfaces  of  the  thighs.  In 
one  case  under  the  author's  observation  the  trophic  changes  in 
the  skin  consequent  upon  a  long-continued  idiopathic  pruritus 
stopped  suddenly  half-way  down  the  nymphae,  a  sharply  defined 
serpiginous  line  dividing  the  healthy  and  the  diseased  surfaces. 
Idiopathic  pruritus  is  a  disease  usually  of  middle  and  advanced 


Fig.  121. 


-Pruritus  vulvse,  showing  hypertrophied  nymphse  and  clitoris  and  leuko- 
plakia. 


age.  The  itching  is  worse  at  night  and  is  increased  by  warmth 
or  exercise.  The  congestion  of  the  menstrual  periods  and  of 
pregnancy  increases  it.  The  patient,  driven  almost  distracted, 
scratches  herself  savagely,  excoriating  the  tissues.  She  is  unable 
to  sleep.  She  is  unfitted  for  society,  becomes  melancholic,  and 
perhaps  insane.  The  irritation  of  the  genitalia  excites  the  sexual 
appetite,  which  is  gratified  by  masturbation  or  excessive  coitus. 
The  disease  often  comes  under  medical  observation  after  it  has 
lasted  for  years  and  is  inveterate  in  its  resistance  to  treatment. 

Treatment. — Pruritus  vulvae   should   be    regarded   as  symp- 
tomatic  until  it  is  proved   to   be  otherwise.      Before  treating  it, 


I02  Diseases  of  the  Vulva 

therefore,  a  careful  search  for  the  cause  should  be  instituted. 
First  and  foremost  the  urine  must  be  examined  for  sugar.  Then 
a  careful  investigation  must  be  made  of  the  external  and  of  the 
internal  genitalia,  of  the  digestive  organs,  the  diet,  and  the  sys- 
temic condition  in  general. 

For  the  pruritus  of  diabetes,  dietetic  management,  local 
cleanliness,  and  the  protection  of  the  vulva  by  borated  talcum 
powder,  or  a  boracic  acid  ointment,  are  indicated.  Mercurial 
and  sulphur  ointments  are  required  for  pediculi,  scabies,  and 
ringworm  ;  boracic  acid  washes  for  thrush.  The  ingrowing  hairs 
of  trichiasis  must  be  extracted.  Gout  and  rheumatism,  diseases 
of  the  vagina,  uterus,  tubes  and  ovaries,  fistula  and  fissure  in  aiw, 
and  hemorrhoids  require  appropriate  treatment.  Seat-worms 
indicate  enemata  of  infusion  of  quassia.  Errors  in  diet  should 
be  avoided,  and  the  prolonged  use  of  a  drug  forbidden.  The 
sexual  hygiene  may  need  supervision.  For  idiopathic  pruritus 
the  following  local  applications  have  been  recommended  :  Cocain 
in  a  I  to  I o  per  cent,  solution;  carbolic  acid  in  solutions  of 
varying  strength  ;  nitrate  of  silver  solution  ;  menthol  in  stick  or 
in  an  ointment  combined  with  acetate  of  lead,  chloral  and  cam- 
phor ;  corrosive  sublimate  in  strong  solutions  (gr.  j  in  f Sj  of 
emulsion  of  bitter  almonds,  or  alcohol  and  water,  aa  fSss); 
ethereal  solution  of  iodoform  sprayed  into  the  folds  of  the  vulva ; 
tincture  of  opium,  iodin,  and  aconite,  aa  f5v;  lead-water  and 
laudanum  ;  chloroform,  f  5j,  and  glycerin,  f 5j  ;  dilute  hydro- 
cyanic acid,  gtt.  ij,  water,  fSj  ;  infusion  of  tobacco;  vinegar; 
vaginal  suppositories  of  ichthyol,  i  part,  glycerin,  2  parts  ;  very 
hot  water  or  an  ice-bag;  subcutaneous  injections  of  normal  salt 
solution,  1  to  ^  of  a  liter;  exposure  to  the  x-ray  and  electricity 
in  the  form  of  faradism,  rapidly  interrupted  galvanism,  or  the 
high-frequency  static  current.  A  patient  under  the  author's 
observation,  treated  in  vain  for  many  years  by  a  number  of 
specialists,  and  to  whom  he  had  recommended  the  excision  of 
the  labia,  cured  herself  by  using  carbolic  acid  mixed  with  milk 
in  strong  solutions.  Internal  as  well  as  local  treatment  may  be 
necessary.  Cannabis  indica  and  the  bromids  are  the  two  drugs 
most  to  be  depended  upon. 

If  the  disease  resists  other  treatment  it  may  be  cured  by 
the  excision  of  the  affected  structures,  usually  the  nymphse  and 
clitoris,  possibly  the  inner  surfaces  of  the  labia  majora.  This 
operation  was  first  proposed  and  performed  by  Schroeder.  The 
wound  is  an  inverted  V  in  shape.  The  raw  surfaces  are  easily 
covered  by  healthy  skin  and  mucous  membrane,  which  are 
brought  together  by  interrupted  sutures. 

^  Siebourg,  "  Centralbl.  f.  Gyn.,"  No.  26,  1901. 


Kraurosis  Vulvae  103 

Another  and  a  better  surgical  treatment  is  the  resection  of  the 
nerves  supplying  the  skin  of  the  vulva.  Sir  James  Y.  Simpson 
cites  Dr.  Burns,  of  Glasgow,  as  the  first  to  recognize  "hyperesthe- 
sia and  neuralgia  of  the  vulva"  and  to  cut  the  pudic  nerve  for  it, 
which  he  attempted  by  an  incision  that  came  nowhere  near  the 
nerve.  Simpson's  subcutaneous  section  of  the  nerve  was  even 
less  likely  to  injure  it.  From  time  to  time  this  proposition  has 
been  renewed,  but  has  usually  been  founded  on  insufficient 
anatomical  knowledge,  to  say  the  least.  The  author  has  cured 
three  inveterate  cases  by  the  resection  of  the  genital  branch  of  the 
genitocrural,  the  ilio-inguinal,  the  perineal  branches  of  the  pudic, 
the  nerve  of  the  dorsum  of  the  clitoris,  and  the  inferior  or  long 
pudendal  nerve  on  both  sides.  Four  incisions  are  required:  two 
over  the  external  inguinal  rings  through  the  deep  fascia;  two 
along  the  inner  edges  of  the  ascending  rami  of  the  ischia,  from 
the  tuberosity  to  a  point  two  inches  above  it.  The  nerves  are 
not  only  cut,  but  as  long  a  peripheral  end  as  possible  is  pulled 
out.  If  the  clitoris  is  involved  in  the  pruritus,  it  is  necessary  to 
resect  its  dorsal  nerve,  which  requires  a  deep  dissection  of  the 
ischiorectal  fossa,  through  the  inferior  layer  of  the  triangular 
ligament.  The  nerve  is  found  to  the  inner  side  of  the  ascend- 
ing ramus  of  the  ischium  on  the  outer  side  of  the  pudic  artery. 
The  perineal  branch  of  the  pudic  is  on  the  inner  side  of  the  artery. 

Kraurosis  vulvae  was  first  described  and  named  by  Breisky^ 
in  1885,  who  reported  twelve  cases.  The  disease  is  an  atro- 
phic process  of  the  skin  of  the  vulva  involving  the  labia 
minora,  the  clitoris,  and  extending  in  rare  cases  to  the  perineum 
and  the  mons  veneris,  where  there  may  be  complete  alopecia. 
The  nymphae  amost  or  quite  disappear,  the  clitoris  shrinks, 
the  skin  is  thickened,  white  in  color,  smooth  and  shiny,  ex- 
hibiting numerous  small  abrasions  and  fissures.  The  vaginal 
entrance  is  narrowed.  The  pathological  changes  in  the  skin  are 
a  thickening  of  the  epidermis,  a  disappearance  of  the  rete  Mal- 
pighii,  a  sclerosis  of  the  corium,  which  is  infiltrated  with  small 
cells,  a  diminution  of  the  prominence  of  the  papillae,  a  complete 
disappearance  of  the  sebaceous  glands,  and  an  almost  complete  dis- 
appearance of  the  sweat-glands.  The  nerves  and  nerve-endings 
are  unaltered.  Peter  ^  describes  the  disease  as  a  chronic  inflam- 
matory hyperplasia  of  the  connective  tissue,  with  a  tendency  to 
cicatricial  contraction,  inflammatory  edema  of  the  upper  corium 
layer  and  of  the  epidermis,  with  degeneration  of  the  elastic  tissues. 

The  symptoms  are  often,  but  not  always,  an  intense  pruritus, 
burning  on  urination,  a  feeling  of  contraction  or  stretching  when 

^  "Zeitschr.   f.    Heilkunde,"  Bd.  vi,  p.  69.      upavpou,  to  shrink, 
*  "Monatsschr.  f.  Geburtsh.  u.  Gyn. ,"  Bd.  iii,  p.  297. 


I04 


Diseases  of  the  Vulva 


walking,  and  dyspareunia.      The  contracted  vulvar  orifice  predis- 
poses to  extensive  tears  in  labor  if  the  patient  is  pregnant. 

The  causes  are  obscure  :  A  long-continued  pruritus  may  be 
followed  by  kraurosis.  It  is  a  disease  usually  of  middle  and 
advanced  age,  so  that  senile  atrophy  may  be  a  predisposing 
cause.  It  has  been  traced  to  irritating  leukorrhea,  extensive 
injuries  to  the  perineum,  and  to  the  removal  of  the  ovaries.  It 
is  often  inexplicable.      Epithelioma  has  developed  in  a  consider- 

b 


9  "h- 

Fig.  122.  —  Kraurosis  vulvae;  microscopic  section  through  the  excised  skin: 
a,  Thickened  and  swollen  corneal  layer;  a^,  spot  of  hyaline  degeneration  and  leuko- 
cytes in  corneal  layer  ;  b,  exudate  between  epidermis  and  corium  ;  c,  edema  of  the 
upper  corium;  d,  shrunken  granulation  tissue;  e,  e' ,  hairs;  /,  fat;  g,  nerves;  h, 
muscle  (Peter). 

able  proportion  of  cases.  Kraurosis  is  apparently,  therefore,  a 
predisposing  cause.  One  set  of  observers  has  found  the  disease 
most  frequently  in  pregnant  women  ;  another,  in  women  not 
pregnant  and  too  old  to  conceive. 

The  treatment  should  be  the  application  of  astringent  and 
.sedative  solutions  in  the  incipiency  of  the  disease  and  the  excision 
of  the  affected  area  when  the  atrophic  process  has  become  self- 
limited. 


Cyst  of  the  Labium  Alajus 


lO'- 


Tlie  prognosis  is  not  favorable.  Applications  arc  only  pallia- 
tive. The  removal  of  the  atrophic  area  has  given  satisfactory 
results  in  cases  reported  by  IMartin  and  others,  but  there  has 
been  a  recurrence  in  several  of  the  operative  cases. 

Cysts  and  Benign  Tumors  of  the  Labia,  Vestibule,  and 
Groins. — A  cyst  of  the  labium  majus  may  develop  in  the  vulvo- 
vaginal gland  in  consequence  of  closure  of  the  duct.  It  is  com- 
monly small  in  size,  but  ma\'  reach  extraordinary  dimensions. 
A  small  cyst  should  be  dissected  out  without  evacuation  of  its 
contents.  The  deep  cavity  remaining  is  closed  by  interrupted 
sutures,    a    horse-hair    drain    (strands    of  silkworm-gut)    being 


Fig.  123. — Cyst  of  labium  majus  (W.  J.  Taylor). 

inserted  beneath  the  stitches.  If  the  cyst  is  very  large,  its  com- 
plete excision  may  be  a  formidable  undertaking  on  account  ot 
hemorrhage.  It  may  therefore  be  more  convenient  to  excise  the 
greater  part  of  it,  packing  the  cavity  that  remains  and  painting 
the  remnant  of  the  cyst-wall  daily  with  iodin  until  the  secreting 
surface  is  destroyed  by  ulceration,  when  the  cavit\'  is  allowed  to 
close  by  granulation. 

The  vulva  may  be  the  seat  of  cysts  that  occur  on  the  skin 
anywhere  ;  retention  cysts  of  the  sebaceous  glands ;  lymph  cysts 
or   dermoid   cysts.      They   are   punctured   or   excised.      A  solid 


io6 


Diseases  of  the  Vulva 


.< 

\ 

-^"' 

m 

t- 

i 

1 

1 

■ 

.5 

I 

1 

m 

it 

J 

1 

/^ 

-""3*« 

" 

i 

Fig.  124. — Cyst  of  the  right  labium  majus. 


/ 

\ 

^ 

/ 

mf^^^ 

^K'      Iv      ^*''*-«'ii('^HL                 "^'*W*2 

i^y^y 

j^^^^^HmH^9b>'  /f'Jai 

W 

Fig.  125. — Elephantiasis  vulvse. 


Elephantiasis  Vulvae 


107 


Fig.  126. — Elephantiasis  vulvae. 


Fig.  127. — Elephantiasis  vulvae  :  c.t,  Hypertrophied  connective  tissue  ;  s,  thickened 
squamous  epithelium;   l.s,  dilated  lymph-spaces  (McConnell  and  J.  C.  Hirst) 


io8 


Diseases  of  the  Vulva 


Fig.  128. — Operation  for  elephantiasis  vulvas  of  moderate  degree. 


Fig.  129. — Steps  in  operation  for  elephantiasis. 


Elephantiasis  Vulvae 


109 


Fig.  130. — Labia  amputated  for  elephantiasis. 


Fig.  131. — Appearance  of  vulva  three  weeks  after  amputation  of  labia. 


no 


Diseases  of  the  Vulva 


tumor  of  the  labium  minus  or  majus  is  usually  s.  Jibrovta  or  a 
lipoma.  The  removal  of  the  growth  ordinarily  presents  no  great 
difficulty,  especially  if  it  is  pedunculated. 

Elephantiasis  of  the  vulva  is  usually  seen  only  in  tropical 
countries.  The  labia  grow  to  such  a  huge  size  that  they  hang  to 
the  knees.  The  pathological  anatomy  shows  a  vast  overgrowth 
of  connective-tissue  elements  with  dilated  lymph-spaces.  The 
treatment  is  excision.  Special  means  to  control  hemorrhage 
must  usually  be  taken.  The  best  plan  is  to  transfix  the  base  of 
the  growth  with  skewers  and  to  apply  a  rubber  band  above. 
The  blood-vessels  are  ligated  separately,  after  the  excision  of  the 


Fig.  132. — Varices  of  vulva. 


labia,  before  the  skewers  and  band  are  removed.  Syphilitic 
hypertrophy  of  the  connective  and  other  tissues  of  the  labia  may 
produce  an  elephantiasis  of  moderate  degree.  It  is  not  uncom- 
mon, sometimes  yields  to  specific  treatment,  and  may  not  require 
an  operation.  If  the  specific  treatment  is  of  no  avail,  however, 
the  mass  may  be  excised,  usually  with  the  labium  majus  and 
nymphae  on  one  or  both  sides  and  the  clitoris. 

Varicocele  of  the  Vulva.— Varices  of  the  labia  are  seen  usually 
in  pregnancy,  but  sometimes  persist  after  delivery.  If  the 
dilated  veins  are  troublesome  or  threaten  to  rupture,  they  may  be 
excised  between  ligatures  as  in  varicocele  of  the  scrotum. 


PLATE  4. 


^A^%%j^ 


.  .-s.-'/^^iv^  ^'^^i^-^Xi. 


Types  of  urethral  caruncles  :      i ,  Painless  caruncle ;   2,  3,  neuromatous  and  intensely- 
sensitive  caruncles. 


Urethral   Caruncle 


III 


Urethral  Caruncle.— A  neuroma  or  an  angioma  of  the  mucous 
membrane  surrounding  the  external  urinary  meatus  more  prop- 
erly belongs  among  the  vulvar  tumors  than  among  the  diseases 
of  the  urinary  apparatus.  These  growths  are  a  deep  scarlet  in 
color,  vary  in  size  from  that  of  a  millet  seed  to  a  cherry,  are 
single  or  multiple,  and  grow  from  the  mucous  membrane  around 
or  within  the  meatus,  occasionally  springing  from  the  urethral 
canal  at  a  considerable  distance  from  its  termination.  They  are 
usually  pedunculated,  but  may  be  sessile.  The  pedicle  is  often 
lono-   and   slender,    the   tumor   hanging   between   the   labia  and 


Fig.  133. — Urethral  caruncle:   s,  Squamous  epithelium  inflamed  and  thickened;  dy 
dilated  blood-vessels;  cJ,  connective  tissue   (McConnell  and  J.  C.  Hirst). 


being  laterally  compressed  by  them.  In  structure  they  are  com- 
posed of  connective  tissue  and  dilated  blood-vessels  covered  by 
a  thickened  mucous  membrane  with  hypertrophied  papillae.  In 
many  of  the  growths  there  is  a  hypertrophy  and  hyperplasia  of 
nerve-fibers  and  terminals.  In  these  neuromatous  tumors  there  is 
such  excessive  sensitiveness  that  the  woman  suffers  agony  when 
she  urinates.  She  can  not  bear  the  slightest  touch  upon  the 
growth.  Coitus  is  impossible.  Even  locomotion  may  cause 
exquisite  pain,  and  in  time  there  develops  a  long  train  of  reflex 
neurasthenic  symptoms  and  a  marked  deterioration  of  the  gen- 
eral health.      The  diagnosis  is  made  by  the  symptoms  and  by  an 


112 


Diseases  of  the  Vulva 


Fig.   134. — Fibromyoma  of  round  ligament. 


Fig.    135. — A  libromyonia  of    llie  round  ligament  in  the  inguinal  canal.      Weight, 

6l4  ounces. 


Urethral   Caruncle  113 

inspection  of  the  vulva.  The  treatment  is  the  excision  of  the 
oTowth  or  growths,  care  being  taken  to  pull  them  outward  by  a 
rat-toothed  forceps,  which  seizes  them  at  the  base,  and  to  excise 
at  least  an  eighth  of  an  inch  of  healthy  mucous  membrane  with 
them.  Otherwise  they  will  recur.  The  small  wound  is  closed 
with  catgut.  It  is  much  more  satisfactory  to  operate  upon  the 
patient  anesthetized,  but  it  is  possible  to  remove  the  growth  after 
cocainization  with  a  10  per  cent,  solution.  Instead  of  removal 
b\'  excision  the  caruncle  may  be  destroyed  by  cauterization  with 
the  electrocautery  needle,  which  is  plunged  into  it  a  number  of 
times   down  to   its   base.      Cocainization  of  the   part  makes  the 


Fig.  136. — Fibromyoma  of  round  ligament ;  tumor  weighed  6)4  ounces:  f.t.  Fibrous 
tissue;  w,  muscular  tissue;  v,  blood-vessel  (McConnell  and  J.  C.  Hirst). 

operation  painless,  and  it  may  be  carried  out  as  an  office  treat- 
ment. 

If  the  caruncle  is  an  angioma  without  neuromatous  elements, 
it  is  painless,  and  the  patient  is  unaware  of  its  existence,  which 
is  accidentally  discovered  in  the  course  of  a  gynecological  exam- 
ination.    The  removal  of  such  a  growth  is  unnecessary. 

The  groin,  the  inguinal  canal,  and  the  upper  portion  of  the 
labium  majus  may  be  the  seat  of  a  solid  or  cystic  tumor,  which 
ma\^  be  a  fibromyoma,  a  lipoma,  a  sarcoma,  an  adenomyoma,  a 
cystofibroma,  a  dermoid,  or  a  hydrocele  of  the  round  ligament.  The 
first  is  spherical,  possibly  irregular  in  outline.      It  may  be  small 


114  Diseases  of  the  Vulva 

in  size,  confined  to  the  inguinal  canal,  or  it  may  grow  upward 
toward  the  umbilicus  or  outward  toward  the  ilium.  It  may  be 
densely  adherent  to  the  anterior  superior  spine  of  the  ilium  and 
to  the  peritoneum  which  clothes  its  under  surface,  so  that  its 
removal  may  necessitate  a  large  opening  into  the  peritoneal  cavity. 
It  is  stony  hard  in  feel,  and  presents  none  of  the  symptoms  of 
inguinal  hernia,  except  the  tumor  in  the  groin.  The  incision  for 
the  removal  of  the  tumor  is  made  like  that  of  an  Alexander's 
operation  parallel  with  the  Poupart's  ligament,  but  much  longer 
and  through  the  deep  fascia.  The  wound  must  be  carefully  and 
firmly  approximated,  layer  by  layer,  with  continuous  sutures  of 
durable  catgut  to  prevent  hernia.  ^ 

Hydrocele  of  the  round  ligament  is  a  cystic  tumor  in  the  canal 
of  Nuck.  It  may  communicate  with  the  peritoneal  cavity,  in 
which  case  the  swelling  disappears  on  pressure  or  is  increased 
if  the  intraperitoneal  tension  is  augmented,  as  in  coughing  or 
straining.  If  the  canal  is  closed  by  adhesive  inflammation  at  the 
internal  ring,  the  tumor  is  not  affected  by  intra-abdominal  pres- 
sure, is  unmistakably  cystic  in  feel,  and  is  not  tender  on  moderate 
pressure.  Exploratory  puncture  with  a  hypodermic  needle  with- 
draws a  clear  serous  fluid.  If  the  swelling  is  reducible,  a  truss 
should  be  worn  ;  if  it  is  not,  the  sac  may  be  punctured  and  a 
few  drops  of  iodin  injected  to  secure  its  obliteration.  The  most 
satisfactory  treatment  is  excision  of  the  entire  sac,  which  is  dis- 
sected out  of  the  inguinal  canal.  The  wound  is  closed  by  con- 
tinuous catgut  sutures,  layer  by  layer.  Cases  of  hematocele  and 
hematoma  of  the  round  ligament  have  been  reported.^ 

Rodent  Ulcer  of  the  Vulva. — L'esthiomene  (Huguier),  ulcus 
rodens  vulvae  (Virchow),  and  lupus  vulvae  are  names  bestowed 
by  various  observers  upon  an  ulcerative  process,  found  only,  as 
a  rule,  in  prostitutes,  beginning  in  the  fossa  navicularis,  extend- 
ing to  the  labia  and  urethra,  resulting  in  rectovaginal  fistulae, 
and  destruction  of  the  lateral  urethral  walls.  There  is  a  sharp 
dividing  line  between  the  diseased  and  healthy  surfaces,  but 
in  the  latter  there  is  extensive  infiltration  and  edema  and  in  time 
an  elephantiasis.  There  may  be  stricture  of  the  rectum  below 
the  fistulous  opening  in  the  bowel.  In  consequence  of  the  de- 
struction of  the  lateral  urethral  walls,  the  lower  wall  of  the  urethra 
hangs  in  front  of  the  vaginal  entrance.  There  is  little  left  of  the 
urethral  canal,  and  its  mucous  membrane  is  covered  by  squa- 
mous epithelium.      There  are  not  necessarily  tubercles  in  the  ul- 

1  Nebesky  has  collected  30  cases  of  fibromyomata,  to  which  the  author's  2  cases 
should  be  added;  18  cases  of  fibroid  tumors  with  epithelial  structures  in  them, 
2  dermoids,  3  lipomata,  and  4  sarcomata.  "Monatsschr.  f.  Geb.  u.  Gyn.,"  April,  1903. 

2  Koppe,  "  Centralbl.  f.  Gyn.,  "  1886,  vol.  x,  p.  179.  Gottschalk,  ibid.,\o\.  xi, 
P-   329- 


Tuberculosis  of  the  Vulva  115 

cerated  area,  and  the  tubercle  bacilH  can  not  be  found  except  in 
accidental  or  secondary  infection.  The  patient's  general  health 
is  not  affected.  The  causes  to  which  this  peculiar  disease  has 
been  ascribed  are  violent  and  excessive  coitus,  especially  if  the 
\ulva  is  situated  more  anteriorly  than  normal ;  the  removal  of  the 
inguinal  glands  in  cases  of  suppurating  buboes  (F.  Koch)  ;  a  pre- 
existing elephantiasis;  uncleanliness,  and  an  old  syphilitic  in- 
fection. 

The  prognosis  is  unfavorable.  In  the  earlier  stages  cleanli- 
ness and  rest  have  effected  a  cure.  Later,  cauterization  with 
strong  caustics  is  indicated  ;  excision  of  hypertrophied  areas  in 
which  elephantiasis  has  developed  may  be  called  for.  In  one 
case  the  diseased  area  posteriorly  and  the  constricted  bowel  were 
removed,  an  inguinal  anus  being  established  by  fastening  the 
lower  end  of  the  sigmoid  flexure  to  an  opening  in  the  abdominal 
wall. 

Tuberculosis  of  the  Vulva. — Lupus  Vulvae. — According  to 
Koch,  the  only  ulceration  of  the  vulva  to  which  the  name  lupus 
should  be  given  is  dependent  upon  tubercular  infection  demon- 
strated by  the  presence  of  tubercle  bacilli. 

Tubercular  ulceration  of  the  vulva  is  very  rare.  The 
disease  comes  under  the  physician's  observation  only  in  the 
ulcerative  stage,  when  upon  the  perineum,  the  labia,  or  in  the 
vestibule  a  grayish  ulcer  of  varying  size  may  be  seen,  exhibiting 
tubercles  in  process  of  cheesy  degeneration,  and  friable,  feebly 
nourished  granulations,  with  a  serpiginous  edge.  Tubercle  bacilli 
are  found  in  the  recent  ulcerations,  but  may  be  absent  from  the 
old.  There  is  an  attempt  at  cicatrization  in  the  older  portions  of 
the  diseased  area  never  seen  in  cancer,  while  nodes  shortly 
becoming  ulcerated  on  the  surface  mark  the  advance  of  the  dis- 
ease. According  to  Veit,  there  is  never  an  elephantiasis  of 
surrounding  tissues  on  the  border  of  the  tuberculous  inflamma- 
tion, as  in  the  labia,  the  nymphae,  and  the  clitoris,  lupus  thus 
being  distinguished  from  rodent  ulcer  ;  but  in  two  cases  in  which 
an  operation  was  performed  for  elephantiasis  of  the  clitoris 
tuberculosis  was  discovered  on  histological  and  bacteriological 
investigation — perhaps,  however,  as  a  secondary  infection.  The 
explanation  of  the  infection  is  not  easy  to  find.  It  has  been 
attributed  to  coitus  with  a  tubercular  man  ;  to  tuberculosis  of  the 
lungs  or  other  organs,  especially  the  internal  genitalia,  the  urinary 
tract,  and  the  bowel  ;  to  direct  inoculation  with  finger-nails  ;  and 
even  to  the  atmosphere.  Lupus  vulvae  may  be  the  initial  lesion 
of  tuberculosis,  but  it  is  more  likely  to  be  secondary  to  other 
tubercular  processes  in  the  body.  It  occurs  most  frequently  in 
women  from  twenty  to  forty,  but  has  been  seen  as  early  as  the 
eighth  and  as  late  as  the  eightieth  year. 


ii6 


Diseases  of  the  Vulva 


The  treatment  is  the  same  as  for  lupus  elsewhere  ;  excision 
with  the  knife  or  curet,  deep  cauterization  with  caustics,  or,  best 
of  all,  with  the  x-rays,  and  the  actinic  ray,  the  surrounding  healthy 
tissues  being  protected  by  a  lead  screen  or  zinc  foil,  and  the  ulcer- 
ated or  diseased  area  being  exposed  to  the  electric  and  ultra- 
violet rays  eight  to  ten  minutes  daily. 

The  prognosis  depends  upon  the  association  of  other  tuber- 
cular lesions  in  the  body.  If  the  tuberculosis  of  the  vulva  is 
primary,  a  cure  may  confidently  be  expected.      If  there  is  general 


Fig.  137- — Microphotograph  of  section  from  a  case  of  lupus  vulvas  :  a.  Squamous 
epithelium ;  b,  subcutaneous  connective  tissue  ;  c,  tubercle  ;  d,  giant-cell  (McConnell 
and  J.  C.  Hirst). 


miliary  tuberculosis,  or  if  it  is  localized  also  in  the  lungs,  peri- 
toneum, internal  genitalia,  bladder,  or  bowel,  the  lupus  vulvae  is 
likely  to  recur,  or  to  persist  until  the  patient's  death. 

Carcinoma,  Sarcoma,  and  Syphilis  of  the  Vulva. — The 
vulva  is  less  frequently  the  seat  of  cancer  than  any  other  portion 
of  the  genitalia.  Winckel  saw  it  only  twice  in  io,000  women 
examined.  He  collected  62  cases,  40  in  women  over  fifty  years  of 
age,  6  in  women  under  forty.  A  few  cases  of  adenocarcinoma  of 
the  vulvovaginal  gland  and  2  of  Skene's  ducts  of  the  urethra  have 
been  reported  ;    with  these  exceptions  cancers  of  the  vulva  are 


Epithelioma  of  Vulva 


117 


Fig.  138. — Epithelioma  of  vulva. 


Fig.  139. — Epithelioma  of  vulva, 


ji8  Diseases  of  the  Vulva 

epithelioma.  The  clitoris  and  the  labia  majora  are  the  usual 
sites.  A  nodule  first  appears  with  small  neighboring  nodes  ; 
ulceration  of  the  surface  quickly  follows.  The  inguinal  glands 
are  soon  involved,  and  the  epithelioma  of  one  labium  very  shortly 
spreads  to  the  opposite  side.  There  is  a  rapid  extension  of  the 
malignant  infiltration  and  ulceration  to  the  perineum,  the  mons 
veneris,  and  up  the  vagina,  especially  along  the  course  of  the 
urethra.  The  squamous  epithelium  of  the  vulva  has  a  strong 
power  of  resistance  against  all  infections,  so  that  an  epithelioma 
of  the  vulva  may  develop  slowly  and  the  prognosis  is  better  than 
in  cancers  of  the  vagina  ;  but  at  the  best  the  patient's  outlook  is 


^  1 

E*^\ 

■>           / 

m  ff 

!^       \ 

■    IK.' 

^       \ 

■      HV 

^^i^'        A 

X 

^^^mk 

\ 

^^^^k 

"^^ 

•^^^^^^^ 

^^^'^^^l^ 

..mtm^^ySi^i^i^^^^^-^ 

n^ .  ^             1 

Fig.  140. — Inoperable  epithelioma  of  vulva. 

none  too  good.  Recurrence  has  been  noted  in  a  large  percent- 
age of  the  cases,  but  the  proportion  of  permanent  cures  has 
markedly  increased  since  the  adoption  of  the  good  surgical 
principle  that  the  inguinal  glands  should  be  removed  with  the 
tumor,  whether  they  are  demonstrably  diseased  or  not. 

The  treatment  should  be  an  early  and  complete  excision  of 
both  labia,  the  clitoris,  the  lower  portion  of  the  mons  veneris, 
and  the  inguinal  glands.  The  wound  has  somewhat  the  shape 
of  a  W.  It  can  usually  be  brought  together  by  interrupted 
sutures,  but  it  may  be  necessary  to  remove  so  much  tissue  that  a 
portion  of  it  must  be  allowed  to  gape  and  to  heal  by  granula- 


PLATE  5. 


Sarcoma  of  the  Vulva 


119 


tion.      It  has  been  found   necessary  in  some  cases  to  remove  the 
whole  urethra  and  to  resect  the  descending  ramus  of  the  pubis. 

Sarcoma  of  the  vulva  is  very  rare.  It  is  usually  of  the 
melanotic  variety.  The  tumor  is  rounded  in  shape,  has  reached 
the  size  of  a  cocoanut,  though  it  is  usually  of  moderate  dimen- 
sions, and  may  be  pedunculated.  The  labia  and  the  urethral 
region  are  the  sites  from  which  the  growth  develops.  Two  cases 
have  come  under  the  author's  observation.  One  appeared  directly 
after  labor  in  the  Maternity  Hospital  of  the  University  of  Penn- 
sylvania, as  melanotic  nodules  on  the  labia.       Within  four  weeks 


Fig.  141. — Sarcoma  of  left  labium  minus. 


the  patient  died  of  general  sarcomatosis,  with  melanotic  sarcoma 
of  the  liver,  kidney,  breast,  and  the  subcutaneous  connective  tissue 
everywhere.  The  other  case  was  a  sarcoma  of  the  left  labium 
minus.  The  growth  was  excised.  There  was  no  local  recur- 
rence, but  general  sarcomatosis  appeared  in  six  months. 

The  growth  should  be  removed  from  the  vulva  as  soon  as 
detected,  but  recurrence  and  metastases  are  to  be  expected. 
Reed,^  however,  reports  a  permanent  success. 

1  "  Text-book  of  Gynecology,"  p.  230,  1901. 


I20 


Diseases  of  the  Vulva 


Fig.  142. — Sarcoma  removed  and  split  open. 


Fig.   143. — Syphilis  of  the  vulva. 


Syphilis  of  the  Vulva 


121 


Syphilis  of  the  vulva  is  considered  in  this  connection  on 
account  of  its  resemblance  to  cancer  in  some  of  its  manifesta- 
tions. In  an  early  stage  of  the  disease,  with  the  initial  sore  on 
a  labium,  mucous  patches  within  the  vagina,  and  flat  condylomata 
on  the  buttocks,  thighs,  and  vulva,  the  appearance  is  distinctive 
enough  and  could  not  well  be  mistaken  for  anything  else.  But 
the  syphiloderm  of  an  old  infection  cannot  be  distinguished  from 
cancer  at  first  sight;  not  indeed  until  specific  treatment  has  been 


~-^ 

^m 

i 

'■l 

f 

^ 

^. 

-- 

^ 

-i,' 

^^r^^Stm 

i 

9bv-;^ 

1 

1 

1^' 

•^^ 

n 

i' 

HS 

p 

f. 

\ 

Fig.  144. — Syphilis  of  the  vulva. 


tried  or  a  portion  of  the  growth  has  been  subjected  to  micro- 
scopical study.  Mercury  and  iodid  of  potassium  have  often  a 
wonderful  effect  on  old  vulvar  syphilis,  but  if  the  elephantiasic 
processes  accompanying  syphilitic  vulvitis  are  well  advanced, 
it  may  be  necessary  to  excise  the  growth.  Specific  treatment, 
however,  should  first  be  tried.  Local  applications,  best  in  the 
shape  of  antiseptic  and  astringent  dusting-powders,  diminish  the 
discomfort  and  uncleanliness  of  the  moist  secreting  surfaces  of  the 


122  Diseases  of  the  Vulva 

syphilitic  growths  until  it  is  determined  whether  medicinal  treat- 
ment will  suffice  or  surgical  intervention  is  required. 

Pudendal  Hernia. — Inguinal  hernia  in  women  does  not 
differ  from  the  same  condition  in  men,  except  that  the  abdominal 
contents  descend  into  the  labium  instead  of  the  scrotum,  and  must 
be  differentiated  from  tumors  pecuHar  to  that  locality.  The 
symptoms  and  treatment  are  the  same  in  both  sexes.  There  is  a 
pudendal  hernia  peculiar  to  women  in  consequence  of  a  defect  in 
the  pelvic  fascia  and  the  levator  ani  muscle  anterior  to  the  broad 
ligament.  A  peritoneal  pouch  containing  omentum  alone  per- 
haps, but  more  likely  intestines,  descends  along  the  lateral  vaginal 
wall  to  the  posterior  end  of  a  labium  majus.  If  the  intra-ab- 
dominal pressure  is  increased  from  any  cause,  as  by  a  pregnant 
uterus,  an  enormous  enterocele  may  completely  block  the  vaginal 
canal,  giving  rise  to  a  constipation  approaching  obstruction  of  the 
bowels  and  forming  an  obstacle  in  labor  of  a  serious  nature.  The 
coverings  of  the  hernia  have  burst,  allowing  the  intestines  to 
escape.  The  vaginal  and  labial  tumors  have  the  physical  signs 
characteristic  of  a  hernia:  tympany  on  percussion,  recession 
within  the  abdominal  cavity  on  pressure,  unless  the  intestines  are 
adherent  to  the  hernial  ring,  and  a  characteristic  doughy  feel 
with  gurgling  on  palpation. 

The  palliative  treatment  is  first  to  reduce  the  hernia  and  then 
to  prevent  its  recurrence  by  the  use  of  a  globe  pessary,  which 
is  retained  either  by  a  T-bandage  or  napkin,  or  by  a  stem  attached 
to  the  globe  supported  by  a  specially  constructed  belt.  (See  the 
apparatus  for  prolapse,  p.  68). 

The  radical  treatment  for  vaginal  hernia  is  carried  out  by  the 
following  steps :  an  incision  in  the  lateral  vaginal  vault  over  the 
site  of  the  ring  which  can  be  felt ;  opening  the  peritoneal  pouch ; 
release  of  the  intestines  from  adhesions,  if  they  exist;  excision 
of  the  peritoneal  pouch ;  freshening  the  edges  of  the  hernial 
ring;  placing  closely  set  interrupted  sutures  of  silkworm-gut 
through  the  whole  depth  of  the  wound ;  closing  the  ring  with  a 
running  buttonhole  stitch  of  catgut  (formalin) ;  finally  closing 
the  wound  by  uniting  the  interrupted  sutures,  which  are  removed 
in  two  weeks. 

Diseases  of  the  Clitoris. — The  clitoris  may  be  the  seat  of 
cystic  and  solid  tumors,  and  may  be  involved  in  tuberculosis  and 
elephantiasis  of  the  vulva.  There  may  be  adhesion  of  the  pre- 
puce to  the  glans,  with  retention  of  smegma  and  a  consequent 
irritation  causing  severe  reflex  symptoms  or  nymphomania.  Con- 
cretions have  been  found  under  the  prepuce  in  cases  of  long 
standing.  It  has  been  claimed  that  preputial  adhesions  which 
prevent  a  free  exposure  of  the  glans  clitoridis  account  for  a  loss  of 


Injuries  of  the  Vulva  123 

sexual  feeling,  which  returns  when  the  glans  is  freed  (Bernardy). 
To  expose  the  glans  and  break  up  adhesions,  a  surgeon's  probe 
or  a  grooved  director  is  used,  a  point  of  entrance  being  gained 
with  the  end  of  the  instrument.  The  separated  surfaces  are  well 
cleansed  and  thoroughly  packed  to  prevent  a  recurrence  of  the 
adhesions.  The  packing  must  be  renewed  every  other  day  for 
some  time  until  the  abraded  surfaces  are  well  covered  with 
healthy  mucous  membrane. ' 

Tumors  of  the  clitoris  are  cysts,  enchondromata,  horny  epi- 
thelial growths,  epitheliomata,  elephantiasis,  or  simple  hyper- 
trophy. Whatever  their  nature,  the  treatment  is  the  same ; 
removal  of  the  growth  and  usually  with  it  the  whole  clitoris. 
Clitoridectomy  is  performed  by  making  a  circular  incision  around 
the  prepuce  and  the  lower  surface  of  the  free  end  of  the  clitoris  ; 
a  linear  incision  toward  the  pubis  over  the  back  of  the  clitoris, 
which  is  then  dissected  out  and  amputated  at  its  base,  bleeding 
vessels  being  caught  and  tied  and  the  wound  united  with  close- 
set  interrupted  sutures  or  a  continuous  catgut  suture  in  tiers,  as 
the  operator  prefers. 

Injuries  of  the  Vulva. — The  vulva,  like  other  external  por- 
tions of  the  body,  is  subject  to  incised,  punctured,  lacerated,  and 
contused  wounds,  but  injuries  in  this  situation  are  rare.  They 
are  usually  due  to  a  fall  astride  some  hard  object,  like  the  frame 
of  a  bicycle,  the  back  or  arm  of  a  chair.  Children  may  run 
splinters  into  the  vulva  while  sliding  on  a  board.  The  author  has 
seen  a  very  extensive  contused  wound  of  the  vulva  from  a  kick. 
There  are  three  peculiarities  of  injuries  to  the  vulva  deserving 
special  consi(^eration.  One  is  the  likelihood  of  profuse  hemor- 
rhage ;  the  second  is  the  possibility  of  lacerations  in  violent 
coitus ;  and  the  third  is  the  possibility  of  a  lacerated  wound  ex- 
tending through  the  anus  into  the  rectum.  The  hemorrhage  may 
be  frank  and  so  profuse  as  to  be  fatal,  especially  if  the  woman 
is  pregnant.  Pressure  controls  the  bleeding  until  the  vessels  can 
be  tied  or  the  wound  is  closed  by  a  continuous  catgut  stitch.  The 
hemorrhage  may  be  subcutaneous,  resulting  in  a  labial  hematoma. 
The  tumor  has  a  characteristic  appearance.  The  color  of  the 
blood  usually  shows  through  the  skin.  The  size  is  rarely  larger 
than  that  of  a  clinched  fist,  except  in  a  pregnant  or  puerperal 
woman.  Rest  and  the  continuous  application  of  an  ice-bag  control 
the  exudation  of  blood  and  keep  the  tumor  from  reaching  larger 
dimensions.  Absorption  of  the  extravasated  blood  may  be  ex- 
pected. If  this  result  is  not  secured  within  a  reasonable  time  (a 
week),  or  if  meanwhile  evidences  of  inflammation  appear,  the 
skin  over  the  hematoma  should  be  incised,  the  blood-clot  turned 
out,  the  cavity  irrigated  and  packed  with  iodoform  gauze.      The 


124 


Diseases  of  the  Vulva 


Fig.  145. — Hematoma  of  the  vulva. 


Fig.  146. — Vulvorectal  fistula  due  to  violence  in  coitus. 


Coccygodynia  1 2  5 

irrigation  and  packing  must  be  repeated  daily  until  the  cavity 
is  closed  by  granulation.  The  prognosis  of  a  labial  hematoma 
is  not  serious  except  in  a  puerpera. 

Injuries  due  to  coitus  are  rare.  They  are  usually  a  laceration 
of  the  hymen  with  profuse  hemorrhage.  A  woman  may  almost 
bleed  to  death  on  her  wedding  night  from  this  cause.  A  vulvar 
tampon  checks  the  hemorrhage  at  once,  until  catgut,  needles,  and 
a  needle-holder  can  be  prepared  to  close  the  wound  and  to  sur- 
round the  bleeding  vessels.  The  author  has  seen  three  serious 
injuries  from  coitus.  A  child  nine  years  old  was  admitted  to  the 
hospital  with  a  complete  laceration  of  the  perineum  and  a  chancre. 
She  had  been  raped  and  infected  by  her  uncle.  In  two  cases,  one 
in  the  Philadelphia  Dispensary,  the  other  in  the  Howard  Hospital, 
there  was  at  the  base  of  the  hymen  posteriorly  a  perforation  which 
extended  upward  and  backward  into  the  rectum.  Such  cases 
should  be  treated  by  excising  the  hymen,  freshening  the  edges  of 
the  vulvorectal  fistula,  and  closing  it  with  close-set  interrupted 
sutures  of  silkworm-gut. 

Complete  lacerations  of  the  perineum  from  violence  and  not 
in  labor  are  rare.  ^  Parrish  reported  one  in  a  female  infant 
from  the  tip  of  a  forceps  blade,  which  an  inexpert  operator  had 
endeavored  to  apply  to  what  he  thought  was  the  head.  Other 
cases  have  been  due  to  falls  on  objects  like  a  rake  handle  or  a 
hay  knife  ;  to  the  horn  of  a  goat  and  to  a  kick.  There  is  always 
profuse  hemorrhage  and  profound  shock.  The  injury  is  repaired 
by  the  same  operative  technic  required  in  the  primary  repair  of  a 
complete  tear  after  labor. 

COCCYGODYNIA. 

In  the  "  New  Orleans  Medical  and  Surgical  Journal,"  for 
May,  1844,  Dr.  J.  C.  Nott,  of  Mobile,  Ala.,  described  an 
operation  by  which  the  last  two  coccygeal  bones  were  re- 
moved for  what  he  called  "neuralgia  of  the  coccyx."  The 
patient,  a  young  woman,  had  had  a  fall  four  years  before,  but 
had  suffered  pain  in  the  coccyx  for  only  ten  months.  From  the 
description  of  her  symptoms  she  was  evidently  profoundly  neu- 
rasthenic. The  last  coccygeal  bone  was  described  by  Dr.  Nott 
as  reduced  to  a  mere  shell  in  consequence  of  caries.  The  ope- 
ration was  followed  by  great  improvement  in  the  symptoms,  both 
locally  and  generally.  Nott's  discovery  was  apparently  soon 
forgotten.  Fifteen  years  later,  in  1859,  Sir  James  Y.  Simpson 
described  a  disease  of  the  coccyx  which  he  said  could  nowhere 
be   found   mentioned  in  books,  and   for  which  he  proposed  the 

'  "Complete  Lacerations  of  the  Perineum  in  Young  Girls,"  J.  Wesley  Bovee, 
"  Amer.  Jour,  of  Obstet.,"  No.  4,  1 900. 


126  Coccygodynia 

name  "coccyodynia."^  He  advocated,  as  the  treatment  for  the 
disease,  subcutaneous  section  of  all  the  tendinous  and  muscular 
attachments  of  the  coccyx,  or  possibly  the  removal  of  the  coc- 
cygeal bones. 

Scanzoni,  in  1861,  referred  to  the  disease  in  a  German  peri- 
odical. ^ 

It  has  been  declared  that  coccygodynia  is  never  seen  in  men. 
This  statement  is  not  quite  correct.  Prof  W.  W.  Keen  writes 
me  that  he  has  no  recollection  of  such  a  case  in  his  practice, 
and  can  find  no  reference  to  it  in  his  card  catalogue  of  patients. 
Dr.  W.  J.  Taylor,  however,  has  operated  upon  two  neurasthenic 
men  for  coccygodynia.  In  the  "Ephemerides  Medico-Physicae," 
there  is  the  record  of  a  case  of  coccygodynia  in  the  male  from  a 
fall  on  the  buttocks.  Men  are  almost  immune  because  they  do 
not  bear  children,  because  the  coccyx  is  better  protected  in  them 
than  in  women  from  external  violence  by  the  higher  situation  of 
the  bone  and  the  closer  approximation  of  the  tuberosities  of  the 
ischia,  and  because  there  are  not  the  same  development  and  mo- 
bility of  the  muscles  of  the  pelvic  floor  and  of  the  gluteal  region. 

Three-quarters  of  the  cases  are  due  to  injuries  in  labor.  Coc- 
cygodynia may  be  the  result  of  a  fall  or  a  diseased  condition  of 
the  joint  between  the  first  and  second  bones  in  women  who  have 
not  borne  children  and  have  not  met  with  an  accident.  There 
is  frequently  temporary  pain  in  a  coccygeal  joint  following  labor, 
due  no  doubt  to  a  strain  of  the  anterior  ligaments  of  the  bone, 
but  disappearing  after  some  months. 

Etiology  and  Pathological  Anatomy. — The  pain  in  the  coc- 
cygeal joints  after  labor  is  easily  understood.  The  backward 
displacement  of  the  bone  by  the  fetal  head  in  exceptional  cases 
ruptures  a  joint,  breaks  the  anterior'  longitudinal  Hgaments  of 
the  bones,  or  if  there  is  complete  ankylosis  of  all  the  joints,  may 
cause  an  oblique  fracture  of  a  coccygeal  vertebra  itself  The 
same  explanation  sufifices  for  coccygodynia  after  a  fall  on  the 
buttocks,  except  that  the  force  is  exerted  in  an  opposite  direc- 
tion ;  the  bone  is  usually  driven  violently  inward  instead  of 
outward,  and  the  posterior  ligaments  are  ruptured.  After  the 
accident,  no  matter  how  caused,  the  muscular  and  ligamentous 
attachments  of  the  bone  give  it  no  rest  and  so  the  injury  can  not 
heal.  With  every  step,  with  every  effort  to  sit  down  or  rise,  with 
every  movement  of  the  sphincter  ani,  the  bone  is  pulled  upon 
and  moved.      The  torn  fibers  of  the   ligaments   or  the  ruptured 

1  "Med.  Times  and  Gazette,"  July  2,  1859;  the  name  is  spelled  in  this  issue 
"coccyodynia"  ;  in  the  collection  of  Simpson's  lectures  edited  by  A.  R.  Simpson,, 
the  name  appears  as  "coccygodynia." 

J  "Wiirzburg.  med.  Zeit.,"  i86i,  Bd.  ii. 


Fig.  147. — Types  of  injuries  and  disease  of  the  coccygeal  joints. 
127 


128  Coccygodynia 

joints  are  thus  constantly  dragged  apart  and  are  never  permitted 
to  heal. 

The  explanation  of  coccygodynia  in  a  woman  who  has  not 
borne  a  child  or  met  with  an  accident  is  more  difficult  and  is  not 
yet  quite  satisfactory.  In  cases  of  the  kind  under  the  author's 
observation  there  was  abnormal  mobility  of  the  joint  between 
the  first  and  second  coccygeal  vertebrae,  and  a  thickened,  ab- 
normally soft  intervertebral  disk  between  the  bones.  All  the 
other  joints,  including  the  sacrococcygeal,  were  firmly  anky- 
losed.  This  variety  of  coccygodynia  occurs  in  women  with 
ankylosis  of  all  the  coccygeal  joints  except  that  between  the 
first  and  second  bones,  and  probably  some  cause  in  them  de- 
termines an  abnormal  movement  of  this  single  joint  ;  perhaps 
hard  work  or  exercise ;  possibly  violence  in  coitus  or  the  pas- 
sage of  large,  firm  masses  of  feces  from  the  rectum.  Once  the 
joints  or  its  ligaments  are  overstretched,  the  sprain  is  never  re- 
lieved, on  account  of  the  muscular  and  ligamentous  pull  upon 
the  bones  already  described.  A  neurasthenic  element  or  a  nervous 
hyperesthesia  may  have  to  be  considered  in  such  cases,  but  it  is 
not  the  main  factor  in  the  symptoms. 

It  is  a  common  idea  that  coccygodynia  is  often  an  expression 
of  rheumatism.  This  belief  had  its  origin  in  Simpson's  description 
of  his  first  case.  In  the  author's  experience  so-called  rheumatic 
coccygodynia  has  almost  always  been  due  to  injury  of  a  joint. 

Following  the  discovery  by  Luschka  of  the  coccygeal  gland  ^ 
there  was  a  disposition  to  attribute  the  pain  of  coccygodynia  to 
injury  or  disease  of  the  gland  to  which  "the  nerve-supply  is  so 
rich  that  one  is  inclined  to  regard  it  as  part  of  the  nervous 
system"  (Luschka).  There  is,  however,  no  valid  argument  in 
favor  of  this  view,  and  there  is  much  against  it. 

The  pathological  anatomy  of  specimens  removed  by  opera- 
tion may  be  thus  summarized  :  In  the  majority  of  cases  there  is  a 
rupture  of  a  coccygeal  joint  or  of  the  ligaments  supporting  it. 
The  second  coccygeal  joint  is  more  often  affected  than  the  first. 
In  these  cases  the  intervertebral  disk  of  the  injured  joint  is 
thickened  and  softened.  There  may  be  a  complete  ankylosis  of 
the  whole  bone,  which  runs  in  a  straight  line  from  the  sacrum 
downward,  so  that  whenever  the  patient  sits  down  she  feels  as 
though  she  were  sitting  on  a  nail.  There  may  be  a  softening 
and  a  hypertrophy  of  the  intervertebral  disk  of  the  first  joint,  with 
relaxation  or  overstretching  of  the  ligaments  without  a  history 
of  injury,  and  in  one  case  there  was  an  oblique  fracture  through 
the  second  coccygeal  bone.^      In  cases  of  injured  coccyges  not 

'"Die  Stei.?.sdru.se  des  Menschen,"  Hubert  lAischka,  "  Virchow's  Archiv," 
Bd.  xviii,  Berlin,  i860. 

''■  Described  and  illustrated  in  the  writer's  "Text-Book  of  Obstetrics." 


Symptoms  and  Diagnosis 


129 


operated  upon  because  there  are  no  symptoms,  the  bone  has 
been  fractured,  or  a  joint  has  been  ruptured,  the  lower  fragment 
is  pulled  forward  at  right  angles  to  the  upper  and  is  firmly 
ankylosed  in  this  position.  As  there  is  no  mobility  there  is  no 
pain,  but  there  would  be  serious  difficulty  in  such  a  case  in  a 
subsequent  labor. 

Symptoms  and  Diagnosis. — The  pain  of  coccygodynia  is  felt  in 
"the  very  end  of  the  spine,"  as  the  patient  expresses  it.  The 
greatest  pain  is  experienced  in  sitting  down  and  rising  from  a 
sitting  posture.  In  the  former  act  the  patient  rotates  her  body 
on  its  long  axis  and  lets  the  weight  of  her  trunk  fall  upon  one 
tuber  ischii.      When  she  rises  she  puts  the  palmar  surface  of  one 


Fig.  148. — Palpation  of  injured  coccyx. 


hand  upon  the  seat  of  her  chair  and  pushes  herself  up  by  her 
arm,  so  as  to  spare  the  gluteal  muscles  and  those  of  the  pelvic 
floor.  There  is  pain  in  defecation  and  in  coitus.  Pressure  over 
the  coccyx  also  elicits  pain.  If  the  coccyx  is  caught  between  the 
forefinger  in  the  rectum  and  the  thumb  in  the  crease  of  the 
nates,  the  lower  fragment  below  the  ruptured  joint  may  be 
thrown  out  of  the  line  of  the  upper  fragment  (Fig.  148).  At  the 
same  time  the  abnormal  and  the  painful  mobility  of  the  bone 
may  be  demonstrated  and  the  sharp  ridge  of  the  upper  fragment 
may  be  felt  when  the  lower  fragment  is  pushed  backward.  It  is 
impossible  to  do  this  with  a  normal  bone. 
9 


130  Coccygodynia 

In  a  very  thin  subject  the  displacement  forward  of  the  lower 
fragment  leaves  a  sharp  ridge  of  bone  at  the  lower  end  of  the  upper 
fragment  that  irritates  the  skin  over  it,  which  is  red,  very  sensi- 
tive, and  from  time  to  time  acutely  inflamed.  There  may  be  a 
constant  distressing  pain  along  the  spinal  column  from  the  nape 
of  the  neck  to  the  end  of  the  spine. 

Treatment. — The  most  satisfactory  treatment  of  coccygo- 
dynia is  coccygectomy.  Simpson,  who  advocated  enthusiastically 
the  subcutaneous  severance  of  all  the  soft  tissues  attached  to  the 
coccyx,  confessed  that  this  operation  had  occasionally  failed.  If 
the  injury  to  the  bone  occurs  in  labor,  or  is  the  result  of  a  fall  or 
a  blow,  it  is  justifiable  to  wait  some  months  for  a  spontaneous 
recovery.  There  are  a  number  of  cases  following  labor  in  which 
the  pain  disappears  after  six  months,  so  that  length  of  time  at 
least  should  elapse  before  resorting  to  operation,  unless  the 
patient's  sufferings  are  too  severe  or  have  too  serious  an  effect 
upon  her  nervous  system.  Meanwhile  counterirritants,  as  ung. 
iodi,  and  rest  may  be  prescribed.  If  no  disease  or  injury  of  the 
bones  or  joints  can  be  demonstrated,  the  pain  is  hysterical  or 
rheumatic,  and  should  be  treated  accordingly. 

The  technic  of  coccygectomy  may  be  thus  described :  The 
woman  is  placed  in  the  Sims'  posture.  The  skin  over  the 
coccyx  is  cleansed  by  the  operator  after  the  patient  has  been 
anesthetized.  A  straight  incision  is  made  in  the  raphe  from  the 
top  of  the  coccyx  to  the  end  of  the  sacrum,  down  to  the  bone. 
The  tissues  are  separated  by  retractors,  and  with  a  heavy  scissors, 
sharp  pointed  and  curved  on  the  flat,  all  the  soft  structures  are 
cut  loose  from  the  bone.  The  forefinger  of  the  left  hand  inserted 
under  the  bone  acts  as  a  guide  and  protects  the  rectum.  If 
there  is  ankylosis  of  the  sacrococcygeal  joint,  it  is  difficult  to  tell 
when  the  top  of  the  cocc\'x  is  reached,  and  the  mistake  is  easily 
made  of  leaving  a  part  of  the  coccyx  behind.  The  alae  of  the 
first  coccygeal  bone  are  the  best  guides.  The  dissection  must 
extend  above  these  points.  Into  the  cavity  beneath  the  isolated 
coccyx  a  sponge  or  gauze  pad  is  stuffed  to  catch  fragments  of 
bone  or  bonedust  and  to  control  hemorrhage.  A  chain  saw  is 
slipped  under  the  bone,  and  pushed  up  so  that  it  takes  off  the  tip 
of  the  sacrum.  Two  or  three  to-and-fro  movements  sever  the 
bone.  The  only  vessel  as  a  rule  requiring  ligation  is  the  median 
sacral  artery,  which  is  tied  with  catgut.  A  drain  of  five  strands 
of  silkworm-gut  is  laid  in  the  rather  deep  wound,  which  is  united 
with  five  or  six  interrupted  silkworm-gut  sutures.  The  wound  is 
scarcely  distinguishable  from  the  raphe  after  a  few  weeks.  The 
result  of  the  operation  is  usually  most  gratifying  in  the  sympto- 
matic relief  afforded. 


PART  IV. 


DISEASES  AND  INJURIES  OF  THE  VAGINA. 

The  vagina  is  a  canal  with  muscular  walls,  lined  with 
mucous  membrane,  flattened  from  before  backward  so  that  the 
anterior  and  posterior  walls  are  in  contact.  It  is  divided  into 
three  portions — the  orifice  or  entrance,  the  body,  and  the  vaults 
or  fornix,  into  which  the  vaginal 
portion  of  the  cervix  projects, 
dividing  tlie  vault  into  the  an- 
terior, posterior,  and  two  lateral 
vaults.  The  vagina  runs  a 
course  upward  and  backward, 
its  axis  corresponding  with  the 
axis  of  the  lower  portion  of  the  ^"" 
pelvic  canal.  It  often  presents 
a  slight  convexity  forward  on 
account  of  the  anterior  curvature 
of  the  rectum  behind  it.  Its  axis 
makes  an  angle  with  the  horizon 
from  behind  of  65  to  70  degrees. 
In  the  middle  of  the  lower  por- 
tion of  the  canal,  both  on  the  an- 
terior and  posterior  w^alls,  there 
is  a  cord-like  thickening,  the 
anterior  and  posterior  columns 
of  the  vagina.  Running  laterally 
from  the  columns  there  are  well- 
marked  rugae  in  young  women 
who  have  not  borne  children. 
On  either  side  of  the  vaginal 
columns,  running  parallel  with 
them,  are  quite  deep  clefts  or 
sulci,  so  that  a  transverse  section 

of  the  vagina  has  the  shape  of  a  letter  H  (Fig.  149).  More  than 
half  the  vaginal  canal  is  below  the  level  of  the  plane  of  the  pelvic 
outlet.      It  has  the  following  average  dimensions  : 

Length  from  orifice  to  external  os  uteri 7.0     cm. 

Length  of  the  anterior  vaginal  wall 7.0 

Length  of  the  posterior  vaginal  wall 8.22 

Breadth  of  the  canal  at  its  middle 2.5 

Depth  of  the  anterior  vault 3.5 

Depth  of  the  posterior  vault 1.75 

Thickness  of  vaginal  wall 0.35 

131 


Fig.  149. — Section  illustrating  the 
characteristic  form  of  the  vaginal  cleft  : 
Ua,  Urethra  ;  Va,  vagina  ;  L,  levator 
ani  ;   R,  rectum  (Henle). 


132  Diseases  and  Injuries  of  the  Vagina 

The  narrowest  portion  of  the  vaginal  canal  is  its  entrance, 
which  is  constricted  by  a  voluntary  ring  muscle,  the  bulbo- 
cavernosus   muscle,  is  narrowed  by  the  bulbs  of  the  vestibule, 


Fig.  150. — Frontal  section  of  female  pelvis:  i,  Fundus  uteri;  2,  rectum;  3, 
right  ureter  ;  4,  peritoneum  ;  5,  vena  cava  ;  6,  aorta  ;  7,  left  common  iliac  artery; 
8,  left  internal  spermatic  vessels;  9,  colon  ;  10,  left  ureter;  il,  psoas  muscle  ;  12, 
ureteric  vein  ;  13,  left  external  iliac  vessels  ;  14,  left  ovary  ;  15,  left  obturator  nerve, 
artery,  and  vein  ;  16,  umbilical  and  vesical  arteries,  left ;  17,  left  uterine  artery  ;  18, 
uterovaginal  plexus,  left;  19,  superior  vesical  vein,  left;  20,  orifice  of  left  ureter; 
21,  vesicovaginal  plexus  ;  22,  left  vaginal  artery  ;  23,  obturator  internus  muscle,  with 
fascia  ;  24,  resected  os  pubis  ;  25,  urogenital  trigonum  muscle,  vessels  and  nerve  of 
the  dorsum  of  the  clitoris ;  26,  posterior  labial  vessels  ;  27,  anastomotic  branch  of 
the  obturator  vein  ;  28,  adipose  tissue  of  the  ischiorectal  fossa;  29,  vestibule  of  the 
vagina  and  carunculae  myrtiformes  or  hymenales  ;  30,  lateral  cutaneous  femoral 
nerve  ;  31,  femoral  nerve  ;  32,  right  superior  umbilical  and  vesical  arteries  ;  ^^,  ob- 
turator nerve  and  vessels;  34,  resected  Fallopian  tube  and  round  ligament;  35, 
parietal  pelvic  fascia;  36,  vaginal  portion  of  cervix;  37,  orifice  of  right  ureter;  38, 
right  vaginal  arteries  ;  39,  obturator  muscles  and  fascia  ;  40,  posterior  column  of  va- 
gina and  vaginal  walls  ;  41,  corpus  cavernosum  of  the  clitoris,  ischiocavernosus  mus- 
cle ;  42,  bulb  of  the  vestibule  and  labium  minus  ;  43,  perineal  fascia  ;  44,  labium 
majus  (Waldeyer) 


and  encroached  upon  by  the  columns  of  the  vagina  and  by  the 
hymen  in  a  virgin,  or  by  its  remnants,  the  carunculae  myrti- 
formes or  hymenales,  in  a  woman  who  has  borne  children.      On 


The  Vagina  133 

the  inner  surface  of  the  anterior  wall  is  a  space  marked  by  a 
trans\'erse  fold  of  mucous  membrane  2.5—3  centimeters  below 
the  external  os  uteri  and  by  two  diverging  lines  beginning  at  the 
top  of  the  anterior  column  of  the  vagina  which  corresponds  with 
the  trigonum  of  the  bladder.  Under  the  outer  walls  of  the 
lateral  vaginal  vaults  are  sometimes  found  the  remains  of  the 
Wolffian  bodies — Gartner's  ducts.  The  muscular  coat  of  the 
vagina  is  divided  into  two  layers,  an  outer  of  longitudinal  fibers 
and  an  inner  of  circular  fibers,  the  latter  being  the  stronger. 
The  mucous  membrane  is  i  — 1.5  millimeters  thick,  firm  in  con- 
sistency, being  composed  of  squamous  epithelium  in  well-marked 
layers.  It  is  richly  provided  with  elastic  fibers  and  is  studded 
with  long  papillae.  In  its  upper  portion  there  are  lymph-follicles. 
Glands  have  been  found  by  a  few  observers,  but  they  are  most 
exceptional.  Waldeyer  has  never  seen  them.  There  is  no  sub- 
mucosa. 

The  arteries  are,  in  the  upper  part,  the  cervicovaginal  branch 
of  the  uterine  artery  ;  in  the  middle  third,  the  inferior  vesical 
artery ;  in  the  lower  third,  the  median  hemorrhoidal  and  the 
internal  pudic. 

The  veins  form  a  plexus  between  the  mucous  and  muscular 
coats,  the  efferent  vessels  accompanying  the  arteries  just  named 
and  emptying  into  the  hypogastric  vein.  There  is  a  complex 
network  of  lymphatic  vessels  under  the  mucous  membrane,  those 
in  the  lower  third  of  the  vagina  emptying  into  the  inguinal 
glands,  those  from  the  middle  and  upper  third  ending  in  the  iliac 
and  hypogastric  glands. 

The  nerve-supply  of  the  upper  part  of  the  vagina  has  the 
same  source  as  the  uterine  nerves.  The  vaginal  vaults  and  the 
vaginal  portion  of  the  cervix  possess  little  sensitiveness  as  a 
rule.  The  pudic  nerve  supplies  the  lower  portion  of  the  vagina. 
The  sympathetic  nerve-fibers  end  in  the  unstriped  muscle  of  the 
vagina  and  in  the  blood-vessel  walls. 

The  vagina  is  supported  and  held  in  position  by  the  muscles 
surrounding  and  inserted  in  it,  and  by  its  connective -tissue  at- 
tachments to  the  bladder  and  urethra  in  front,  to  the  rectum  be- 
hind, and  to  the  cervix  above.  The  attachment  to  the  bladder 
extends  from  the  lower  part  of  the  fundus  to  the  trigonum,  be- 
coming firmer  from  above  downward.  The  connection  with  the 
urethra  is  most  firm. 

The  attachment  to  the  rectum  is  muscular  and  fibrinous,  a 
few  fibers  of  the  levator  ani  muscle  passing  between  the  two  and 
mingling  with  fibers  of  the  internal  sphincter  ani  and  transversus 
perinei  muscles ;  but  the  main  bond  between  the  two  canals  is 
connective  tissue. 


134 


Diseases  and  Injuries  of  the  Vagina 


The  muscles  surrounding  and  inserted  in  the  vagina  are  the 
levator  ani  muscle,  the  bulbocavernosus  muscle,  and  the  uro- 
genital trigonum  muscle.  Intervening  between  the  lower  rectum 
and  the  vaginal  entrance  are  the  transversus  perinei  and  the 
sphincter  ani  muscles. 

The  levator  ani  muscle  sweeps  backward  from  its  attachment 
to  the  anterior  pelvic  bones  and  ligaments  in  a  horseshoe  curve, 
passing  alongside  the   vagina,   though   nowhere  attached  to  it. 


,-^p2:? 


Fig.  151. — The  pelvic  floor  of  the  female  pelvis  from  below,  showing  the 
sphincter  and  retractor  ani  muscles,  the  levator  ani  muscle,  the  pudic  artery  and  the 
nerve  of  the  dorsum  of  the  clitoris  on  its  outer  side,  the  vulvovaginal  gland,  and 
the  bulb  of  the  vestibule  (Deaver). 


encircling  the  rectum  and  sending  some  of  its  fibers  between  the 
rectum  and  the  vagina,  to  be  attached  to  the  perineal  fascia.  The 
muscle  has  a  considerable  breadth  forming  the  segment  of  a 
funnel-shaped  canal  within  its  curve,  slanting  downward,  inward, 
and  forward.  The  contraction  of  this  muscle  pulls  the  rectum 
and  perineum,  and  with  them,  indirectly,  the  vagina,  forward  and 
upward,  contributing  to  the  last-named  the  greatest  part  of  the 


The  Vaorlria 


135 


muscular  and  ligamentous  support  which  holds  it  in  the  normal 
position. 

The  bulbocavcrnos2is  or  constrictor  vagincE  miiscle  in  two  sym- 
metrical halves  encircles  the  vagina,  ending  anteriorly  at  the 
crura  clitoridis  and  posteriorly  in  the  central  aponeurosis  of  the 
perineum,  mingling  some  of  its  fibers  with  the  external  sphincter 


Fig.  152. — Muscular  diaphragm  of  the  pelvis  or  pelvic  floor,  from  above  (male 
subject)  :  i,  Symphysis  pubis  ;  2,  iliac  bone,  resected  ;  3,  sacrum,  resected  ;  4,  coc- 
cyx ;  5,  ischiac  spine  ;  6,  prostate  and  urethra  ;  7,  rectum  ;  8,  internal  obturator 
muscle;  9,  levator  ani  muscle;  10,  coccygeus  muscle;  11,  pyriformis  muscle;  12, 
arcus  tendineus  of  the  levator  ani  muscle;  13,  arcus  suprapyriformis  ;  14,  perineal 
center;  15,  anococcygeal  ligament;  16,  obturator  canal  with  its  nerve  and  vessels; 
17,  suprapyriform  foramen  with  superior  gluteal  artery;  18,  posterior  margin  of  the 
sacrosciatic  ligament.     The  dotted  line  indicates  the  pelvic  outlet  (Testut). 


and  the  transversus  perinei  muscles.  This  muscle  constricts  the 
vaginal  entrance  from  side  to  side  and  pulls  it  forward  with  the 
perineum.  It  also  compresses  the  bulbs  of  the  vestibule  and  the 
vulvovaginal  glands. 

The   muscle  of  the   urogenital  trigonum   in  two   symmetrical 
halves    arises    from    the    ischiopubic     synostosis,    encircles    the 


136  Diseases  and  Injuries  of  the  Vagina 

urethra,  is  inserted  in  the  anterior  and  lateral  walls  of  the  vagina, 
and  embraces  it  in  part  posteriorly.  It  furnishes  a  considerable 
portion  of  the  support  which  holds  the  lower  segment  of  the 
vaginal  canal  in  position,  especially  the  anterior  wall.  It  also 
supports  the  urethra. 

The  transverse  perineal  uutscle  slung  across  the  pelvic  floor 
from  the  tuberosities  of  the  ischia  and  united  in  the  middle  by 


Fig.  153. — Median  frozen  section  of  pudendal  region  ;  virgin,  twenty-four  years 
old:  I,  Symphysis  pubis  ;  2,  suspensory  ligament  of  clitoris;  3,  corpus  cavernosum 
clitoridis  ;  4,  glans  clitoridis  ;  5,  prreputium  clitoridis  ;  6,  dorsal  vein  of  the  clitoris  ; 
7,  venous  plexus  communicating  with  the  bulbus  vestibuli  and  the  clitoris  ;  8,  8^,  walls 
of  urinary  bladder;  9,  neck  of  the  bladder;  10,  urethra;  11,  11,  external  sphincter 
muscle  of  the  urethra;  12,  external  meatus;  13,  labium  minus;  14,  labium  majus ; 
15,  vestibule  of  the  vagina;  16,  vaginal  entrance;  17,  17^,  vaginal  venous  plexus; 
18,  carina  urethralis;  19,  hymen  ;  20,  external  sphincter  ani  muscle  ;  20^,  21,  bulbo- 
cavernosus  muscle;  22,  fossa  navicularis ;  23,  fourchet;  24,  vesicouterine  pouch; 
25,  prevesical  space;  x,  x,  plane  of  superior  strait;  y,y,  horizontal  line  through 
lower  edge  of  symphysis  ;  z,  s,  horizontal  line  through  external  meatus  ;  8,  horizontal 
line  through  top  of  symphysis  ;  9,  horizontal  line  through  internal  meatus  (Testut). 


the  strong  perineal  aponeurosis  gives  support  to  the  perineal  body 
and  so  indirectly  to  the  posterior  vaginal  wall. 

Between  the  lower  rectum  and  the  vagina  is  the  perineal 
center,  body  or  triangle,  a  mass  of  connective  tissue  and  of  un- 
striped  muscle-fibers  in  which  the  muscles  of  the  perineum  and 
pelvic  floor  are  inserted.  Its  shape  contributes  to  the  nor- 
mal direction  forward  and  outward  of  the  lower  third  of  the 
vagina. 


Inflammation  of  the  Vagina  137 

Inflammation  of  the  Vagina  (Vaginitis;  Colpitis). — Inflam- 
mations of  the  vaginal  mucous  membrane  and  of  the  submucous 
connective  tissue  are  almost  always  due  to  infection.  The  com- 
monest infecting  agent  is  the  gonococcus.  Other  causes  of  inflam- 
mation are  the  irritation  and  ulceration  following  the  long 
retention  of  foreign  bodies  ;  atrophic  changes  in  the  mucous 
membrane,  leading  to  ecchymoses  ;  desquamation  of  epithelium 
and  ulceration  due  to  senile  degeneration  or  to  the  deficient  nutri- 
tion and  the  irritation  of  a  prolapsed  vagina  ;  the  ulcerations 
associated  with  dysentery,  typhoid,  and  other  infectious  fevers  or 
following  the  introduction  of  caustics,  such  as  iodin,  carbolic 
acid,  chlorid  of  zinc ;  the  irritating  discharges  of  a  cancer  or 
myoma  of  the  uterus  and  of  a  pelvic  abscess.  Infectious  micro- 
organisms besides  the  gonococcus  causing  vaginitis  are  the  bacilli 
of  diphtheria,  the  streptococci  of  erysipelas,  the  pyogenic  strep- 
tococci and  staphylococci,  tubercle  bacilli,  the  bacillus  aerogenes 
capsulatus  and  fungi  identical  with  or  allied  to  the  thrush  fungus, 
leptothrix,  o'idium  albicans,  monilia  albicans,  monilia  Candida, 
and  yeast  fungi. 

The  manifestations  of  colpitis  vary  with  the  infecting  agent, 
the  cause  of  irritation  and  ulceration,  and  the  stage  of  the  dis- 
ease. Granular  colpitis  is  the  commonest  form.  The  vaginal 
mucous  membrane  is  reddened  and  studded  with  papillae,  which 
are  heaps  of  granulation-cells  under  the  epithelium.  There  is  a 
profuse  discharge  caused  by  a  serous  exudate,  the  exfoliation  of 
epithelium,  and  the  outwandering  of  small  round-cells  through 
the  interstices  of  the  epithelium.  At  first  the  discharge  is  mainly 
serous,  but  it  quickly  becomes  a  creamy  pus,  often  with  bubbles 
of  gas  in  it.  This  is  the  type  of  inflammation  seen  in  gonorrhea. 
With  a  profuse  purulent  discharge  bathing  the  vulva  and  matting 
the  pudendal  hairs  ;  a  vulvitis ;  an  infection  of  the  urethra  and  of 
the  ducts  of  the  vulvovaginal  glands,  and  the  discovery  ofgono- 
cocci  in  the  discharge,  the  diagnosis  is  positive.  In  senile  colpitis 
there  are  ecchymotic  spots  and  perhaps  actual  ulceration,  the 
intervening  mucous  membrane  appearing  healthy.  A  mycotic 
inflammation  displays  a  moderate  reddening  of  the  mucous  mem- 
brane, which  is  covered  here  and  there,  especially  upon  the 
vaginal  portion  of  the  cervix,  with  whitish  plaques,  sometimes 
easily  removed,  again  not  detachable  without  leaving  a  bleed- 
ing surface  behind.  Under  the  microscope  the  characteristic 
fungi  are  discovered  in  the  substance  removed.  Streptococcic 
infection  produces  a  yellowish-green  pseudomembrane  on  the 
mucous  surface  ;  diphtheria  bacilli,  a  dirty  grayish  membranous 
exudate.  There  is  an  exudative  or  desquamative  colpitis  {col- 
pitis gummosa,  Winckel)  which  is    apparently    not    due  to    an 


138  Diseases  and  Injuries  of  the  Vagina 

infectious  inflammation.  It  is  sometimes  associated  with  mem- 
branous dysmenorrhea,  and  occurs  in  neurotic  women  who  are 
subject  to  that  disease.  An  infection  of  the  connective  tissue 
around  the  vagina,  paracolpitis,  dissecting  colpitis,  may  result  in 
the  exfoliation  of  part  or  all  of  the  vaginal  mucous  membrane, 
leaving  granulating  surfaces  behind;  which  are  prone  to  unite, 
causing  stenosis  or  even  atresia  of  the  vagina.  The  infection  of 
the  vaginal  mucous  membrane  by  the  gas  bacillus  produces 
numerous  vesicles  in  the  vaginal  mucous  membrane  {colpoJiy- 
pcrplasia  cystica,  Winckel),  from  which  the  fluid  which  first  fills 
them  may  disappear,  being  replaced  by  a  gas  {colpitis  emphysema- 
tosa) demonstrated  by  Zvveifel  to  be  trimethylamin. 

The  treatment  of  colpitis  varies  with  the  causes  and  manifes- 
tations. Gonorrhea  of  the  vagina  should  be  recognized  at  once, 
and  should  be  treated  with  the  utmost  care  and  energy.  The 
patient's  health  and  comfort  in  the  future — nay,  her  very  life — 
may  depend  upon  the  eradication  of  the  specific  infection  before 
it  has  spread  from  the  vagina  to  the  uterine  and  tubal  mucous 
membranes,  whence  it  may  never  be  dislodged  except  by  radical . 
operative  treatment. 

Gonorrheal  colpitis  is  most  often  seen  in  pregnant  women. 
In  non-pregnant  adults  the  vaginal  mucous  membrane  is  so 
resistant  that  the  specific  infection  is  usually  confined  to  the  other 
mucous  membranes  of  the  genito-urinary  tract.  In  young  girls 
and  infants  there  may  be  an  intense  specific  inflammation. 

The  patient  with  vaginal  gonorrhea  should  be  confined  to 
bed.  Her  diet  should  be  light,  consisting  mainly  of  milk ; 
copious  draughts  of  water  should  be  drunk  to  produce  a  diuresis 
that  shall  frequently  flush  out  the  urethra.  Twice  a  day  the 
patient  should  be  put  in  the  dorsal  position  across  the  bed  or  on 
a  table,  her  hips  resting  on  a  Kelly  pad  with  a  slop  jar  or  bucket 
under  it.  The  vulva  is  thoroughly  cleansed  with  warm  water, 
pledgets  of  cotton,  and  a  small  quantity  of  tincture  of  green 
soap,  the  light  soap-suds  being  washed  off  with  a  permanganate 
•of  potassium  solution  (saturated  solution,  f oj,  to  Oij  water)  poured 
over  the  vulva  from  a  pitcher.  The  vagina  is  then  douched  with 
at  least  two  quarts  of  a  warm  permanganate  solution,  the  hand 
of  the  nurse  or  the  physician  being  placed  against  the  vulvar 
orifice  from  time  to  time  in  order  to  retain  the  fluid  in  the  vagina, 
distend  its  canal,  and  so  force  the  fluid  into  all  the  folds  of  the 
vaginal  mucous  membrane.  After  the  douche,  residual  per- 
manganate solution  is  washed  out  with  a  little  sterile  water,  a 
skeleton  bivalve  speculum  is  inserted,  and  by  this  means  a  large 
pledget  of  absorbent  cotton  soaked  in  a  5  per  cent,  argyrol  solu- 
tion is  introduced.      The  speculum  is  withdrawn  and  the   cotton 


Inflammation   of  the  Vagina  139 

allowed  to  remain  five  minutes.  After  its  withdrawal  a  tampon  of 
lanili's  wool  saturated  with  boroglycerid  is  inserted  in  the  vagina 
b)'  means  of  a  bivalve  or  Sims'  speculum  and  cotton  forceps 
and  is  allowed  to  remain  till  the  next  treatment.  For  the 
boroglycerid,  glycerole  of  tannin  or  tannic  acid  dusted  on 
the  tampon  may  be  substituted.  The  vulva  is  then  dusted 
with  powdered  boracic  acid  in  all  its  folds,  and  a  vulvar  pad  of 
sterile  gauze  and  cotton,  also  dusted  with  boracic  acid,  is  adjusted 
and  retained  by  a  T-binder.  ^  If  the  patient  is  first  seen  after  the 
inflammation  has  existed  a  considerable  time,  or  if  the  treatment 
just  described  does  not  subdue  the  inflammation  in  a  week,  the 
vaginal  mucous  membrane  should  be  bathed  in  a  nitrate  of  silver 
solution,  20  grains  to  the  ounce,  which  is  most  conveniently  done 
by  inserting  a  cylindrical  milk-glass  speculum  until  the  cervix  is 
engaged  in  its  distal  end  and  then  pouring  into  it  about  an  ounce 
of  the  silver  solution.  As  the  speculum  is  slowly  withdrawn 
successive  folds  of  the  vagina  prolapse  into  its  extremity  and  are 
bathed  in  the  solution.  After  the  speculum  is  withdrawn  a  douche 
of  plain  water  with  a  pinch  of  salt  in  it  is  given,  to  wash  out  the 
silv^er  salt  and  to  convert  it  into  the  insoluble  chlorid.  The 
patient's  clothing  should  be  raised  well  above  her  waist,  as  the 
sih'er  solution  stains  everything  with  Avhich  it  comes  in  contact. 
If  one  or  two  of  these  applications  on  successive  days,  or  forty- 
eight  hours  apart,  do  not  remove  the  symptoms  of  vaginitis,  the 
whole  vaginal  canal  should  be  wiped  out  with  glycerin  and  car- 
bolic acid,  equal  parts,  on  a  pledget  of  cotton  through  the  skeleton 
speculum,  the  buttocks  and  labia  being  protected  by  petrolatum 
and  a  douche  of  water  and  alcohol,  equal  parts,  being  adminis- 
tered immediately  afterward. 

For  a  chronic  vaginitis  with  profuse  leukorrhea,  and  for  the 
later  stages  of  vaginal  gonorrhea,  an  astringent  and  antiseptic 
douche  of  sulphate  of  zinc,  5ss,  and  powdered  alum,  5j,  to  the 
quart  of  water  is  useful.  By  the  treatment  described,  vaginal 
gonorrhea  rapidly  disappears,  leaving  the  mucous  membrane  per- 
fectly healthy  in  appearance.  But  gonococci  may  lurk  for  years 
in  the  vulvovaginal  glands,  in  Skene's  glands  of  the  urethra,  in  the 
uterine  mucous  membrane  and  especially  in  the  cervical  glands, 
where  they  are  incited  to  renewed  activity  by  any  congestion  of  the 
pelvis  or  by  any  reduction  in  the  vitality  of  the  patient.  Thus, 
there  may  be  recurrent  attacks  of  gonorrhea  without  fresh  infection. 
A  wife  infected  by  her  husband,  and  apparently  cured  has   rein- 

'  Abraham  advocates  the  insertion  of  vaginal  suppositories  composed  of  yeast, 
asparagin,  and  gelatin.  The  favorable  influence  of  yeast  upon  leukorrhea  was  known 
to  Hippocrates.  The  author  has  no  experience  with  this  treatment.  "  Monatsschr. 
f.  Geburtsh.  u.  Gyn.,"  Bd.  xvi,  1902. 


140  Diseases  and  Injuries  of  the  Vagina 

fected  him  after  his  apparent  cure,  thus  giving  rise  to  a  suspicion  of 
her  infidehty.  A  prostitute  may  infect  only  one  of  a  number  of 
men  who  cohabit  with  her,  or  may  not  infect  any  one  for  a  time,  but 
in  consequence  of  a  drunken  debauch  or  a  pelvic  congestion  from 
xold,  suddenly  becomes  virulently  infectious  to  all  who  come  in 
contact  with  her.  The  treatment  of  chronic  or  recurrent  gonor- 
rhea, therefore,  should  usually  include  the  slitting  up  of  the  ducts 
of  the  vulvovaginal  glands  and  of  Skene's  glands,  and  their  cau- 
terization with  pure  carbolic  acid,  or  disinfection  by  the  injection 
of  strong  argyrol  solution  (10  to  50  per  cent.),  through  a  blunt 
hypodermic  needle,  a  curettage  of  the  uterus  ^  and  an  application  to 
its  cavity  of  carbolic  acid  and  glycerin,  equal  parts,  and  possibly 
amputation  of  the  cervix. 

Ulcerations  of  the  vagina  yield  readily,  as  a  rule,  to  localized 
applications  of  nitrate  of  silver  solution,  gr.  xx— foj,  and  the  in- 
sertion of  boroglycerid  tampons,  which  not  only  allay  congestion, 
but  also  prevent  agglutination  of  raw  surfaces.  Senile  vaginitis 
with  an  irritating  serous  leukorrhea  responds  in  a  most  gratifying 
manner  to  vaginal  suppositories  with  glycerin  as  a  base,  impreg- 
nated with  the  milder  antiseptics,  such  as  thymol,  eucalyptol,  etc. 
The  suppository  is  inserted  at  bedtime,  a  napkin  is  worn  through 
the  night,  as  the  suppository  melts  and  thus  gives  rise  to  dis- 
charge. In  the  morning  a  boracic  acid  douche,  5j  to  the  quart, 
is  taken. 

Colpohyperplasia  cystica  or  colpitis  emphysematosa  is  treated 
by  puncturing  the  vesicles,  which  do  not  refill,  and  administering 
a  boracic  acid  douche.  The  disease  usually  appears  in  pregnant 
women,  in  whom  local  treatment,  except  in  the  last  month  of 
gestation,  should,  if  possible,  be  avoided  on  account  of  the  risk 
of  inducing  a  miscarriage  or  premature  labor.  Streptococcic  in- 
fection of  the  vaginal  mucous  membrane,  with  a  yellowish -green 
pseudomembrane,  does  surprisingly  well,  as  a  rule,  on  daily  irri- 
gations with  sterile  water  and  general  stimulation  and  support. 
Small  localized  infections  may  be  treated  by  applications  of  a 
strong  nitrate  of  silver  solution.  True  diphtheritic  membrane  in 
the  vagina  should  be  touched  with  pure  carbolic  acid  if  the  area. 
involved  is  not  too  extensive,  or  with  nitrate  of  silver  solution, 
oi— f.^j,  if  the  infection  is  widespread. 

Paravaginitis,  phlegmonous  vaginitis,  or  infectious  inflamma- 
tion of  the  perivaginal  connective  tissue,  is  treated  on  general  sur- 
gical principles :  early  and  extensive  incisions  into  the  inflamed 
areas;   detachment  of  sloughs  as  soon  as  practicable,  and  vaginal 

^  Curettage  for  gonorrheal  endometritis  is  recommended  with  some  reservation 
(page  359).  It  may  be  replaced  by  intra-uterine  irrigation  or  applications  of  argyrol. 
solution. 


Tuberculosis  of  the  Vagina  141 

packing  or  tampons  to  prevent  agglutination  of  granulating  sur- 
faces. During  the  sloughing  period,  when  considerable  masses 
of  <'-angrenous  vaginal  mucous  membrane  may  be  retained  in  the 
vagina,  gauze  packing  or  wool  tampons  dusted  with  charcoal 
diminish  the  odor  and  lessen  the  chances  of  septic  intoxication. 

Tuberculosis  of  the  vagina  is  rare  on  account  of  the  resis- 
tance of  the  squamous  epithelium  of  its  mucous  membrane  to  in- 
fection. When  it  does  occur,  it  is,  as  a  rule,  the  result  of  an 
infection  from  the  uterus,  so  that  the  posterior  vaginal  vault  is  the 
usual  site  of  the  tubercular  ulcer.  If  the  infection  spreads  from 
the  vulva,  the  lower  portion  of  tlie  vagina  is  involved.  Vaginal 
tuberculosis  is  ordinarily  associated  with  tubercular  inflammation 
in  other  portions  of  the  genitalia;  in  the  bladder,  bowel,  peri- 
toneum, or  distant  organs,  as  the  lungs,  or  a  joint.  There  is, 
however,  a  case  of  primary  tuberculosis  of  the  vagina  on  record.^ 
The  sources  of  infection  are  discharges  from  the  uterus,  from  a 
rectovaginal  or  a  vesicovaginal  fistula ;  the  blood  ;  infected  hands 
or  instrument;  the  male  organ  in  coitus;  infected  clothing,  or  the 
atmosphere.  The  symptoms  are  pain  in  coitus  or  on  the  insertion 
of  a  syringe,  and  a  vaginal  leukorrhea,  associated  usually  with 
the  symptoms  of  tuberculosis  elsewhere. 

On  inspection  an  ulcer  is  discovered,  covered  with  a  grayish, 
caseous  exudate,  with  sharply  defined  borders,  serpiginous  in 
outline,  surrounded  by  reddened  infiltrated  mucous  membrane,  in 
which  miliary  tubercles  may  be  seen.  In  later  stages  of  the 
disease  fistulous  openings  appear  into  the  bowel,  bladder,  urethra, 
or  perineum,  or  communicating  with  an  infected  tube.  The 
differential  diagnosis  from  cancer  and  syphilis  is  made  by  the 
discovery  of  tubercle  bacilli  in  a  bacteriological  study  and  by 
inoculation  experiments  with  guinea-pigs,  in  which  tuberculosis 
is  caused  by  injecting  the  tubercular  material  from  the  surface  of 
the  ulcer  ;  by  removing  a  small  portion  of  the  tissue  around  the 
edge  of  the  ulcer,  which  shows  under  the  microscope  in  cases  of 
cancer  the  characteristic  cell-proliferation,  or  in  tuberculosis  mil- 
iary tubercles  ;  and  in  the  case  of  syphilis  by  the  therapeutic  test. 

The  treatment  of  vaginal  tuberculosis  is  only  palliative  if  it 
is  associated  with  tuberculosis  elsewhere,  as  is  almost  invariably 
the  case.  If  the  vaginal  ulcer  is  the  primary  lesion,  it  may  be 
excised,  or  cauterized  by  the  actual  cautery  or  by  a  50  per  cent, 
solution  of  chlorid  of  zinc. 

Acquired  Stenosis  and  Atresia  of  the  Vagina. — By  acquired 
stenosis  is  meant  the  narrowing  of  the  vagina  by  cicatricial  con- 
traction.     By  acquired  atresia  is  meant  the  obliteration  of    the 

^  Carl  Friedlander,  "  Lokale  Tuberculose,"  "  Samml.  klin.  Vortrage,"  Volk- 
mann,  No.  64. 


142  Diseases  and  Injuries  of  the  Vagina 

canal  by  the  agglutination  of  apposed  granulating  surfaces  and 
by  cicatricial  contraction. 

The  causes  of  stenosis  and  atresia  of  the  vagina  are  the  in- 
juries of  labor  and  their  injudicious  repair  ;  plastic  operations  with 
too  extensive  denudation  and  faulty  insertion  of  sutures  ;  the  long 
retention  of  foreign  bodies  in  the  vagina  and  consequent  ulcera- 
tion ;  inflammations  and  ulcerations  in  childhood,  adult  life,  ^  and 
old  age  ;  and  the  ulceration  of  the  vaginal  mucous  membrane 
which  follows  the  use  of  strong  caustics,  as  chlorid  of  zinc 
applied  to  a  cancer  with  insufficient  precaution  to  protect  the 
vagina,  repeated  applications  of  iodin,  and  even  of  nitric  or  sul- 
phuric acid,  which  have  actually  been  applied  to  the  vagina  to 
induce  abortion. 

The  symptoms  differ  with  the  degree  of  contraction  of  the 
vagina,  the  age  of  the  patient  and  her  social  state.  In  childhood 
complete  atresia  may  occur  after  an  ulceration  of  the  vagina  with- 
out attracting  attention  until  menstruation  begins.  In  a  single 
woman  stenosis  of  the  vagina  may  reach  a  marked  degree  without 
manifesting  itself,  as  the  first  symptom  w^ould  be  dyspareunia  ;  in 
old  age,  after  the  menopause,  stenosis  and  even  complete  atresia 
maybe  discovered  only  by  accident  or  notatall.  Inmarried  women 
stenosis  of  the  vagina  is  a  cause  of  dyspareunia,  and  it  is  on  this 
account,  most  likely,  that  the  patient  seeks  medical  aid.  But 
the  author  has  seen  a  case  of  stenosis  of  the  vagina  by  which 
the  canal  was  reduced  in  its  whole  length  to  a  sinus  not  admit- 
ting a  uterine  sound  ;  the  contraction  had  been  the  result  of 
injury  in  a  labor  eighteen  months  before  ;  coitus  had  been  prac- 
tised frequently,  and  the  condition  was  only  discovered  in  a 
pregnancy  at  term.  In  some  of  these  cases  coitus  takes  place 
by  the  urethra,  which  is  gradually  dilated  to  a  sufficient  extent 
to  admit  the  male  organ,  and,  strangely  enough,  without  inconti- 
nence of  urine  as  a  result.  Impregnation  has  thus  occurred  by 
way  of  a  vesicovaginal  fistula.  On  inspection  and  digital  exam- 
ination of  a  case  of  acquired  stenosis  the  vagina  is  found 
obstructed  by  connective-tissue  bands  or  membranes  stretched 
across  the  canal,  or  by  cicatricial  bands  and  infiltration  encircling 
the  vagina  or  running  longitudinally  under  the  mucous  mem- 
brane. The  obstruction  may  be  confined  to  a  limited  area  or 
may  extend  the  whole  length  of  the  canal.  It  is  usually 
possible  to  insert  at  least  the  tip  of  the  forefinger  through  the 
narrowed  canal,  but  the  vagina  may  be  contracted  to  a  mere 
sinus  scarcely  admitting  a  surgeon's  probe. 

^  Brose  ("Zeitschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  xxiv)  reports  the  extrusion  of  a 
gangrenous  piece  of  vaginal  mucous  membrane  five  days  after  the  crisis  of  a  crou- 
pous pneumonia. 


Treatment  of  Stenosis  143 

Atresia  of  the  vagina  manifests  itself  after  puberty  by  a  re- 
tention of  the  mucosanguinolent  discharges  of  the  genital  tract. 
The  patient  experiences  and  exhibits  the  menstrual  molimhia 
without  a  bloody  discharge.  Pain  in  the  hypogastrium  appears, 
aggravated  at  the  menstrual  periods  ;  a  tumor  slowly  develops 
in  the  lower  abdomen,  increasing  in  size  at  the  periods  and  de- 
creasing somewhat  in  the  intervals,  but  growing  larger  from 
month  to  month  ;  coitus,  if  attempted,  is  found  impossible  or 
unsatisfactory.  On  examination,  the  obliteration  of  the  vaginal 
canal  is  easily  detected.  If  the  closure  begins  near  or  at  the 
orifice,  a  separation  of  the  labia  discloses  it.  If  it  is  situated 
higher,  the  vagina  ends  as  a  blind  pouch,  usually  in  its  upper 
third.  If  the  agglutination  of  the  vaginal  walls  is  confined  to 
a  limited  area,  a  bulging  membrane  is  seen  and  felt,  behind 
which  the  accumulation  of  menstrual  blood  may  easily  be  ap- 
preciated as  a  cystic  tumor.  If  a  considerable  length  of  the 
vagina  is  obliterated,  a  recto-abdominal  examination  is  required 
to  detect  the  extent  of  the  atresia  and  the  accumulation  of 
retained  fluid  above  it.  In  this  examination  account  should  in- 
variably be  taken  of  the  tubal  condition.  There  is  usually  hema- 
tosalpinx, which  may  be  unilateral.  It  is  also  desirable  to  de- 
termine the  approximate  quantity  of  retained  blood  by  the  size 
of  the  tumor  ;  the  involvement  of  the  uterus  in  the  distention 
of  the  genital  canal  (hemelythrometra)  and  the  thickness  of  the 
cicatricial  tissue  between  the  bladder  and  rectum,  which  is  esti- 
mated by  a  sound  in  the  bladder  and  a  finger  in  the  rectum. 

The  treatment  of  stenosis  has  for  its  object  the  dilatation  of 
the  canal.  This  is  accomplished  in  various  ways.  Gradual  dila- 
tation with  bougies  may  suffice  ;  but  the  treatment  must  be  con- 
tinued persistently  a  long  time  and  may  not  lead  to  a  permanent 
cure.  Fibromyxomatous  bands  and  membranes  stretched  across 
the  vagina  should  be  excised.  Usually  there  is  no  occasion  for 
hemostasis,  but  it  is  advisable  to  draw  the  mucous  membrane 
over  the  wounded  surfaces  by  interrupted  sutures  of  catgut. 
Cicatricial  bands  under  the  mucous  membrane  should  be  incised 
as  deeply  as  possible  wherever  they  are  felt  to  be  most  tense. 
They  may  be  torn  by  the  finger  even  more  deeply  than  they  can 
safely  be  cut.  The  mucous  membrane  alone  is  united  over  the 
wounds  with  interrupted  sutures  introduced  in  a  direction  parallel 
with  the  cut,  so  as  fijrther  to  enlarge  and  not  to  contract  the 
vagina.  A  vaginal  plug  (Sims')  of  glass,  hard  rubber,  or  metal 
should  then  be  inserted,  and  should  be  retained  continuously 
for  a  month,  being  removed  daily  to  be  cleansed  and  to  allow 
irrigation  of  the  vagina.  The  plug  should  be  worn  for  a  {ew 
hours   daily  during  the   year  succeeding  the  operation,  being  re- 


144  Diseases  and  Injuries  of  the  Vagina 

tained  by  a  napkin  or  b}'  a  special  apparatus  which  the  author  has 
employed  with  satisfaction  (Fig.  79). 

If  the  stenosis  extends  the  whole  length  of  the  vagina  and  is 
extreme  in  degree,  the  success  of  any  treatment  is  problematical. 
If  the  patient  comes  under  the  physician's  observation  when  she 
is  pregnant,  a  Porro  Cesarean  section  is  required  at  term.  After 
the  removal  of  the  uterus  the  stenosis  of  the  vagina  requires  no 
treatment. 

The  treatment  of  atresia  has  for  its  object  the  restoration  of 
the  cahber  of  the  vagina  and  the  restitution  of  an  external  outlet 
for  the  discharges  of  the  genital  tract.  The  same  principles 
obtain  in  the  treatment  of  congenital  and  acquired  atresia,  but  the 
latter  is  often  more  difficult  to  deal  with.  The  condition  of  the 
tubes  should  receive  the  first  attention.  If  there  is  hematosalpinx, 
the  tubal  sac  should  be  removed  by  an  abdominal  section  before 
the  vagina  is  opened  and  the  blood  in  the  uterus  and  vagina 
is  evacuated.  The  numerous  deaths  after  operations  for  atresia 
have  been  due  to  tubal  infection  or  rupture  and  a  consequent 
peritonitis. 

To  open  the  occluded  vaginal  canal  it  may  be  sufficient  to 
make  a  crucial  incision  in  a  membranous  septum  or  to  excise  it 
at  its  base.  The  retained  blood,  as  thick  sometimes  as  tar,  flows 
out  slowly  and  should  be  thoroughly  washed  away  by  a  boracic 
acid  solution.  The  wounded  surface  encircling  the  vagina,  if 
the  membrane  is  excised,  is  covered  with  mucous  membrane 
by  inserting  interrupted  sutures  from  above  downward,  uniting 
the  mucous  membranes  of  the  healthy  portions  of  the  vagina. 
If  the  atresia  involves  a  considerable  length  of  the  vagina,  a 
blunt  dissection  is  required  between  the  bladder  and  rectum,  with 
a  sound  in  one  and  the  forefinger  of  the  left  hand  or  a  bougie 
in  the  other,  the  tissues  being  separated  by  the  blunt  end 
of  a  closed  scissors,  the  occasional  stroke  of  a  knife,  and  the 
operator's  fingers.  When  the  accumulated  fluid  is  reached  and 
evacuated,  the  opening  which  has  been  secured  by  a  blunt  dis- 
section should  be  enlarged  as  much  as  possible  by  graduated 
bougies,  the  fingers,  or  powerful  branched  dilators,  the  force 
being  applied  laterally  so  as  to  avoid  injury  to  the  bladder  or 
rectum.  The  problem  is  now  to  prevent  a  reclosure  of  the 
canal.  This  has  been  accomplished  in  several  ways:  The  pro- 
longed retention  of  a  plug  with  the  idea  that  the  caliber  of  the 
vagina  shall  be  maintained  while  a  proliferation  and  extension  of 
the  vulvar  epithelium  finally  covers  the  raw  surfaces  with  a  new 
mucous  membrane  ;  the  implantation  of  flaps  gained  by  cutting 
loose  the  labia  minora  except  at  their  bases,  splitting  them  lon- 
gitudinally,  joining  them    together,    suturing    their    edges,  and 


Injuries  of  the  Vagina  and  Pelvic  Floor        145 

inverting  them  into  the  vagina,  where  they  are  sewed  fast 
(KiJstner) ;  implanting  a  tube  of  vaginal  mucous  membrane 
obtained  from  a  prolapsed  vagina  in  another  patient,  as  has  been 
successfully  done  by  Mackenrodt  and  by  the  author  ;i  implant- 
ing intestinal  mucous  membrane  secured  by  resection  of  the 
bowel  in  another  patient  (Kiistner).  In  these  latter  methods 
some  plan  must  be  adopted  to  keep  the  vagina  distended  and  the 
transplanted  flaps  or  implanted  membrane  in  close  apposition 
with  the  raw  surfaces.  A  tampon  left  undisturbed  for  a  number 
of  days  and  a  vaginal  plug  have  been  employed  for  this  purpose, 
but  there  are  objections  to  both  plans.  Noble's  suggestion  to 
insert  a  pouch  of  thin  rubber  tissue  and  to  distend  it  with  gauze 
packing  is  a  good  one.  When  the  newly  made  vagina  is  clothed 
with  mucous  membrane  by  any  one  of  the  methods  just  de- 
scribed, systematic  attempts  to  retain  a  sufficient  caliber  in  the  canal 
should  be  begun  about  three  weeks  after  the  operation,  either 
by  regular  daily  dilatation  with  a  bougie  or  by  the  use  of  the 
vaginal  plug,  worn  daily  for  at  least  an  hour.  Occasionally  the 
most  satisfactory  operation  for  atresia  is  hysterectomy.  In  a 
case  under  the  author's  care  a  LeFort's  operation  on  the  vagina 
had  been  performed  by  another  operator  three  years  before  ; 
on  examination  a  row  of  silver  sutures  was  found  extending 
across  the  vagina,  where  they  had  been  for  three  years.  There 
was  complete  atresia,  with  extremely  firm  cicatricial  contraction, 
a  pyelythrometra,  which  had  ruptured  into  the  bladder,  an  exten- 
sive vesicovaginal  fistula  above  the  site  of  atresia,  double  pyosal- 
pinx,  and  a  general  septic  intoxication.  The  patient  was  cured 
by  a  hysterectomy  and  the  removal  of  the  uterine  appendages. 
With  no  further  discharge  into  the  upper  vagina  the  vesicovaginal 
fistula  closed  spontaneously.  The  atresia  was  not  corrected,  as 
the  only  purpose  of  such  treatment  would  have  been  to  establish 
a  coitional  vagina,  which  experience  has  shown  to  be  impracti- 
cable in  the  absence  of  the  uterus.  Even  were  permanent  suc- 
cess assured,  the  propriety  of  medical  treatment  to  that  end  is 
questionable. 

Injuries  of  the  Vagina  and  of  the  Pelvic  Floor. — The  vagina 
may  be  injured  in  coitus,  especially  if  it  has  undergone  senile 
atrophy  and  contraction,  or  is  superinvoluted,  as  it  may  be 
during  lactation.      The  vaginal  vaults  have  thus  been  penetrated 

^  In  the  author's  case  a  woman  with  total  prolapse  was  operated  upon  first  ;  two 
broad  strips  of  mucous  membrane  were  excised,  sewed  together  with  catgut  around  a 
cylindrical  speculum,  and  placed  in  a  warm  normal  salt  solution.  A  rapid  blunt  dis- 
section was  then  performed  in  the  patient  with  atresia  to  a  depth  of  three  inches. 
The  vaginal  mucous  membrane  on  the  speculum  was  implanted,  the  latter  withdrawn 
after  being  filled  with  iodoform  gauze  which  remained  in  the  vagina  undisturbed  for 
two  weeks. 


146  Diseases  and  Injuries  of  the  Vagina 

and  the  posterior  fornix  has  been  torn  away  from  the  cervix. 
Injury  has  been  inflicted  by  the  indulgence  of  perverted  sexual 
instincts.  In  one  case  a  drunken  brute  inserted  his  whole  hand 
in  the  vagina  and  tore  out  the  woman's  womb.  Falls  upon 
pitchforks  and  broom  handles  or  similar  articles  have  resulted  in 
penetrating  wounds,  and  instruments  inserted  by  unskilled  hands 
to  induce  abortion  have  perforated  the  vaginal  walls.  The 
forcible  insertion  of  too  large  a  pessary  has  lacerated  the  vaginal 
entrance.  Wounds  of  the  vagina  usually  bleed  profusely.  The 
hemorrhage,  however,  can  be  controlled  by  sutures  or  by  gauze 
packing.  If  a  penetrating  wound  of  the  vault  opens  the  peritoneal 
cavity,  cleanliness  and  drainage  often  secure  a  favorable  result. 
The  latter  is  provided  by  the  use  of  gauze  packing  and  a  double 
rubber  drainage-tube.  After  four  or  five  days  the  pelvic  cavity, 
shut  off  by  that  time  by  adhesive  inflammation  from  the  rest  of 
the  peritoneal  cavity,  may  be  irrigated  with  sterile  water  daily 
until  all  discharge  ceases  and  the  water  returns  clear.  If  intes- 
tines prolapse  through  the  vaginal  wound,  they  should  be 
cleansed  by  pouring  sterile  water  over  them,  and  should  be 
returned  into  the  pelvic  cavity,  where  they  are  held  by  gauze 
packing.  A  long  loop  of  intestine  prolapsed  into  the  vagina 
has  become  gangrenous  by  strangulation  at  the  point  of  emer- 
gence through  the  wound.  The  gangrenous  portion  may  be 
excised  and  an  intestinal  anastomosis  performed,  if  necessary,  by 
enlarging  the  vaginal  wound,  when  the  gut  should  be  returned 
to  its  proper  place  and  retained  there  by  packing  the  lower  pelvic 
canal  and  the  open  wound  with  a  long  strip  of  gauze. 

The  most  frequent  injuries  of  the  vagina  by  far  occur  during 
labor.  They  include  rents  in  the  vaginal  vault,  usually  extend- 
ing from  the  cervix  ;  cuts  from  the  edges  of  a  forceps,  lacerations 
of  the  mucous  membrane  by  overdistention  of  the  canal  as  the 
fetal  head  passes  through  it,  and  by  the  insertion  of  a  physician's 
whole  hand.  Associated  with  tears  of  the  vaginal  mucous 
membrane  or  without  visible  injury  to  its  walls  there  are  often 
two  forms  of  injury  in  labor  that  seriously  affect  the  woman's 
subsequent  health  and  comfort.  One  of  these  injuries  is  the 
stripping  of  the  vaginal  walls  from  their  subjacent  attachments 
to  fascia  and  muscle.  The  fetal  head  in  its  descent  pushes  the 
vaginal  walls  in  front  of  it  as  a  glacier  forms  its  morraine,  tear- 
ing the  walls  of  the  canal  loose  so  that  they  have  a  tendency 
later,  when  the  woman  stands  erect,  to  sag  down  and  finally 
become  inverted,  prolapsing  from  the  vulvar  orifice.  This 
glacier-like  action  is  most  commonly  seen  upon  the  anterior 
vaginal  wall,  which  is  nipped  between  the  fetal  head  and  the 
maternal  symphysis,  thrown  into  prominent  transverse  folds,  and 


Injuries  of  the  Vagina  and   Pelvic  Floor         147 

forcibly  pushed  downward  in  front  of  the  presenting  part  until  it 
is  torn  loose  from  its  attachmeiit  to  the  fibromuscular  structures 
that  unite  it  with  the  bladder  and  urethra,  and  which  furnish  a 
considerable  proportion  of  the  support  necessary  to  keep  both 
the  anterior  vaginal  wall  and  the  bladder  in  their  normal  posi- 
tions. In  addition  to  this  form  of  injur}'  there  is  often  a 
hiceration  of  the  fibers  of  the  urogenital  trigonum  muscle  in  the 
anterior  vaginal  sulci.  The  result  is  a  prolapse  of  the  anterior 
vaginal  wall,  the  formation  of  a  pouch  anteriorly  into  which 
the  bladder  naturally  falls  by  gravity.  A  vicious  circle  is  then 
established.  The  more  the  vaginal  wall  descends,  the  deeper 
the  bladder  sinks  ;  the  farther  the  bladder  descends,  the  lower  it 
pushes  in  front  of  it  the  anterior  vaginal  wall,  until  both  emerge 
from  the  vulvar  orifice,  constituting  a  projecting  tumor  called  a 
cystocele.  This  condition  is  all  the  more  likely  to  develop  if  the 
structures  behind  the  vagina  and  in  the  perineum  are  injured, 
robbing  the  anterior  wall  and  the  bladder  of  the  support  naturally 
afforded  them  by  the  muscular  and  ligamentous  tissues  encircling 
the  vagina  posteriorly  and  holding  the  whole  canal  in  its  proper 
position.  But  a  cystocele  may  develop  with  little  or  no  appre- 
ciable injury  to  the  posterior  vaginal  wall,  pelvic  floor,  or 
perineum,  except  an  overstretching  and  relaxation.  The  patient 
with  a  cystocele  experiences  difficulty  in  urination,  and  has  the 
sensation  of  never  completely  emptying  the  bladder,  which 
indeed  she  cannot  do,  as  the  fundus  is  at  a  lower  level  than  the 
neck.  No  sooner,  therefore,  does  she  urinate  than  she  has  the 
inclination  to  pass  water  again.  To  add  to  her  discomfort,  the 
residual  urine  in  the  bladder  decomposes,  causes  a  chronic 
cystitis,  and  in  time  perhaps  a  ureteritis  and  a  pyelitis. 

Very  rarely  the  glacier-like  action  described  affects  the 
posterior  vaginal  wall ;  but  owing  to  the  smooth  surface  of  the 
latter  when  the  vagina  is  distended  in  labor,  its  firm  attachments 
to  the  subjacent  fascia  and  muscles,  the  absence  of  transverse  rugae, 
and  o{  -d.  point  d' appui  against  Avhich  it  can  be  caught  by  the  de- 
scending head,  a  detachment  of  the  posterior  wall  is  very  rare  indeed, 
although  it  can  and  does  occur.  The  other,  the  most  frequent  and 
most  important  injury  of  labor,  is  a  laceration  of  the  muscles 
and  tendinous  structures  of  the  pelvic  floor  and  of  the  perineum 
— the  levator  ani,  the  transversus  perinei  muscles,  and  the  peri- 
neal body.  As  the  fetal  head  descends  in  labor,  the  levator  ani 
muscle  and  to  a  less  extent  the  transversus  perinei  impose  upon 
the  presenting  part  the  new  direction  forward  and  upward  which 
it  must  take  to  escape  under  the  pubic  arch  and  through  the 
vulvar  orifice.  In  the  course  of  this  action  the  sloping  surface  of 
the  frontal  portion  of  the  cranium  displaces  the  muscles   back- 


148 


Diseases  and  Injuries  of  the  Vagina 


ward  until  they  both  describe  a  loop  posteriorly  around  the 
greatest  circumference  of  the  fetal  head  at  the  moment  of  its 
expulsion.  Thus  they  are  relieved  of  a  great  part  of  the  strain  that 
is  at  first  imposed  upon  them,  and  would  continue  to  an  increas- 
ing degree  if  they  maintained  their  original  position  in  relation 
to  the  perineum.  If  anything  interferes  with  the  backward  dis- 
placement of  these  muscles,  as  a  persistent  occipitoposterior 
position,  in  which  the  shape  of  the  occiput  is  not  calculated  to 
push  backward  gently  and  gradually  the  muscular  structure  of 
the  pelvic  floor  ;  if  time  is  not  allowed  for  the  gradual  displace- 
ment and  stretching  of  the  muscles,  as  in  a  precipitate  labor  ;  if, 
even  when  the  muscles  are  normally  and  slowly  displaced,  they  are 


Fig.  154. — Prolapse  of  posterior  wall  of  vagina  with  uterus  at  normal  level. 


put  on  too  great  a  strain  by  a  disproportionate  size  of  the  fetal 
head,  they  tear  in  the  direction  of  least  resistance  and  in  the 
place  where  they  feel  the  greatest  strain  :  the  levator  ani  muscle 
in  one  or  both  posterior  vaginal  sulci  because  the  muscular 
support  is  weaker  at  these  points  than  in  the  median  Hue,  and 
because  the  head  is  oblique  during  the  time  this  muscle  is  sub- 
jected to  greatest  strain  ;  the  transversus  perinei  and  perineal 
body  usually  in  the  median  line,  because  the  head  when  it 
meets  this  muscle  is  directed  with  its  longest  diameter  antero- 
posteriorly,  and  the  strain  is  greatest  in  the  median  line.  The 
subsequent    results,   if  the   injury   is   not  repaired   immediately. 


Injuries  of  the  Vagina  and   Pelvic   Floor         149 

depend  upon  the  muscle  involved  in  the  tear.  If  the  transversus 
perinei  and  perineal  body  alone  are'  lacerated,  the  vulvar  cleft 
is  lengthened,  perhaps  to  the  sphincter  ani.  The  tear  may 
encircle  the  latter  muscle  partially  or  even  completely  without 
involving  its  fibers.  But  the  division  of  the  external  perineum 
causes  the  woman  no  great  discomfort.  The  vaginal  walls  main- 
tain their  normal  position  and  the  canal  its  normal  caliber  after 
childbirth.  The  vulvar  orifice  may  gape,  and  as  a  result  of  such 
a  movement  as  turning  in  bed,  air  may  enter  the  vagina  and  then 
may  be  forcibly  and  audibly  expelled  [garrulity  of  the  vulva) ; 
the  exposure  of  the  mucous  membrane  of  the  vaginal  entrance 
may  cause  an  irritation  and  consequent  vaginal  leukorrhea,  and 
the  enlargement  of  the  vulvar  orifice  may  be  a  cause  of  subse- 
quent sterility  by  permitting  the  escape  of  seminal  fluid  immedi- 
ately after  coitus  ;  but  aside  from  these  disadvantages  which  may 
not  attract  the  woman's  attention,  she  experiences  no  discomfort 
or  disability.  If  the  levator  ani  muscle  is  torn,  the  result  is  much 
more  serious.  The  posterior  vaginal  wall  is  deprived  of  the 
support  which  holds  it  up  and  pulls  it  forward.  It  drops  back 
in  the  supine  position,  and  instead  of  resting  against  the  anterior 
wall  as  it  should,  the  two  are  widely  separated.  The  anus  also 
drops  back  and  is  pulled  backward  by  the  retractor  ani  muscle, 
elongating  the  skin  perineum.  The  vaginal  canal  runs  a  course 
not  forward  and  outward,  but  more  directly  downward  as  the 
woman  stands  erect.  The  posterior  vaginal  wall,  no  longer 
pulled  forward  and  firmly  supported  by  the  levator  ani  muscle, 
sags  downward  in  the  erect  posture,  making  a  pouch  into  which 
protrudes  the  anterior  rectal  wall,  not  separated  from  the  vagina 
by  the  muscular,  fibrinous,  and  elastic  tissues  which  normally 
intervene  between  the  two,  but  in  immediate  contact  with  the 
vaginal  wall.  This  displacement  of  the  anterior  rectal  wall  with 
the  backward  displacement  of  the  anus  gives  to  the  lower  rectum 
an  anomalous  sigmoid  course,  making  the  expulsion  of  feces 
mechanically  difficult.  Chronic  constipation  results,  with  accu- 
mulation of  large  fecal  masses  in  the  rectal  pouch  behind  the 
vagina,  pushing  the  latter  farther  downward  and  outward  until 
the  posterior  vaginal  wall  with  the  anterior  rectal  wall  protrudes  as 
a  tumor,  called  a  rectocele,  from  the  vulvar  orifice.  The  prolapse 
of  the  vagina  drags  upon  the  cervix  and  the  bases  of  the  broad 
ligaments,  predisposing  to  retroversion  of  the  uterus,  to  pro- 
lapsus uteri,  and  to  engorgement  of  the  pelvic  veins.  The 
chronic  engorgement  of  the  latter  leads  to  a  congestion  and 
an  interstitial  hyperplasia  of  the  pelvic  viscera,  especially  the 
uterus,  which  is  further  congested  by  its  malposition.  Hence 
metritis  and  endometritis  are  a  consequence  in  time  of  a  laceratioa 


150  Diseases  and  Injuries  of  the  Vagina 

of  the  levator  ani  muscle.  The  hemorrhoidal  veins  are  overdis- 
tended  by  the  obstructed  pelvic  circulation,  and  hemorrhoids 
are  an  almost  constant  accompaniment  of  extensive  injury  to  the 
pelvic  floor. 

In  a  laceration  of  the  vaginal  sulci  or  of  the  perineum,  if  the 
tearing  force  is  violent  or  suddenly  exerted,  the  tear  may  extend 
through  the  sphincter  ani  and  through  the  rectovaginal  septum 
to   a  varying  height,  sometimes  more  than  two  inches.      If  the 


Fig.  155. — Normal  and  remarkably  well  preserved  vulvar  orifice,  vaginal  introitus, 
and  pelvic  floor  in  a  primipara  six  weeks  after  labor. 


rectal  tear  is  an  extension  from  a  laceration  of  one  vaginal  sulcus, 
as  it  usually  is,  the  injury  of  the  sphincter  and  of  the  septum  is 
always  on  one  side  of  the  median  line;  if  the  laceration  begins 
in  the  perineum,  it  may  extend  directly  backward  in  the  median 
line  through  the  sphincter.  The  result  of  a  complete  laceration 
of  the  perineum  through  the  sphincter  is  usually  incontinence 
of  feces  and  gas.     The  woman  is  unfit  for  company  and  may  be- 


Injuries  of  the  Vagina  and  Pelvic  Floor        151 

come  repulsive  to  her  husband.  She  grows  melancholic  or  de- 
velops a  varied  train  of  reflex  neuroses.  Occasionally,  however, 
complete  continence  is  maintained  in  spite  of  a  tear  through  the 
sphincter  extending  two  inches  up  the  rectovaginal  septum,  and 
the  woman  may  be  so  comfortable  that  she  refuses  treatment. 
Such  a  patient  probably  acquires  the  ability  of  controlling  her 
bowels  by  the  approximation  of  the  gluteal  muscles. 

Finally,  there   may  be  what  is  called   a   central   tear  of  the 


Fig.  156. — Cystocele. 


perineum,  the  fetus  passing  from  the  birth-canal  through  a  perfo- 
ration of  the  perineum  and  not  through  the  vulvar  orifice.  Such 
an  injury,  if  it  is  not  repaired  immediately  or  does  not  close  spon- 
taneously, leaves  a  perineovaginal  fistula. 

The  diagnosis  of  the  various  kinds  and  degrees  of  lacerations 
of  the  pelvic  floor  is  made  by  inspection  and  by  a  digital  exami- 
nation. The  woman  is  placed  in  the  dorsal  gynecological  posi- 
tion for  a  vaginal  examination.      To  recognize  a  tear  of  the  ex- 


152 


Diseases  and  Injuries  of  the  Vagina 


ternal  perineum  and  of  the  transversus  perinei  muscle,  the  labia 
are  pulled  apart  by  the  thumbs.  The  cleft  through  the  perineum 
is  at  once  disclosed  and  its  degree  is  evident.  To  determine  the 
existence  of  an  injury  to  the  anterior  vaginal  wall,  stripping  it 
off  from  its  subjacent  attachments,  the  woman  is  asked  to  cough 
or  to  strain  and  bear  down,  when  the  anterior  vaginal  wall  and 
the  posterior  wall  of  the  bladder  protrude  from  the  vulva.  If 
there  is  any  doubt  as  to  the  nature  of  the  tumor,  a  sound  in 
the  bladder  solves  it.  The  tip  of  the  instrument  is  felt  directly 
beneath  the  vaginal  mucous  membrane  covering  the  cystocele. 


Fig-  i57- — Cystocele  associated  with  large  intraligamentary  ovarian  cyst. 


In  a  suburethral  abscess,  the  only  condition  which  simulates  a 
cystocele,  the  sound  in  the  bladder  is  separated  a  considerable 
distance  from  the  palpating  finger;  there  are  the  local  and  gen- 
eral signs  of  suppuration,  and  pus  exudes  from  the  ducts  of  the 
urethral  glands  when  the  abscess  is  subjected  to  pressure.  In- 
jury of  the  urogenital  trigonum  muscle  is  recognized  by  the 
lower  anterior  vaginal  wall  and  urethra  dropping  backward  in 
the  supine  position  and  protruding  from  the  vaginal  entrance; 
also  by  pressing  the  palmar  surface  of  a  forefinger  upward  in 
each  anterior  sulcus.  If  the  muscle  is  uninjured,  a  muscular 
cushion  is  felt  between  the  finger  and  the  bone;  if  it  is  injured,  the 


Injuries  of  the  Vagina  and   Pelvic  Floor         153 

finger  feels  the  sharp  lower  edge  of  the  pubic  bone  with  nothing 
intervening  except  thin  mucous  membrane. 

The  diagnosis  of  injury  to  the  posterior  vaginal  sulci  and  the 
levator  ani  muscle  is  made  by  several  tests.  The  forefinger  is  in- 
serted in  the  vagina  to  its  second  joint,  and  pressure  is  made 
downward  and  outward  toward  each  tuber  ischii.  It  sinks  in  a 
deep  cleft  and  may  reach  the  pelvic  bones  without  much 
resistance.  The  finger  is  swept  around  the  posterior  wall 
of  the  vagina  from  one  descending  ramus  of  the  pubis  to 
the  other.      On  one   or   both  sides  of  the  median   line  it    sinks 


Fig.  158. — Everting  the  posterior  vaginal  vs^all  by  a  forefinger  in  the  rectum. 


into  a  deep  depression  and  notes  the  absence  of  the  circu- 
lar sweep  of  a  strong  muscular  band  that  is  felt  in  the  normal 
vagina.  Both  fingers  are  inserted  in  the  vagina  and  are  depressed 
toward  the  tuberosities  of  the  ischia ;  the  vagina  gapes  to  an 
astonishing  degree  as  the  posterior  vaginal  wall  is  separated 
widely  from  the  anterior.  The  levator  ani  muscle  is  palpated 
between  the  forefinger  in  the  vagina  and  the  thumb  externally. 
The  thickness  of  the  muscle  and  its  integrity  or  injury  are  ap- 
preciated plainly.  A  finger  in  the  rectum  making  pressure 
forward  and  outward  recognizes  the  pouch  in  the  anterior  rec- 
tal wall,  everts   the  posterior  vaginal   wall  through  the  vulvar 


154  Diseases  and  Injuries  of  the  Vagina 

orifice,  detects  the  absence  of  the  firm  perineal  body  or  triangle, 
and  appreciates  the  tenuity  of  the  mere  skin  perineum  which 
intervenes  between  the  posterior  commissure  of  the  vulva  and 
the  anus.  A  forefinger  in  the  rectum  and  the  thumb  in  the 
vagina  demonstrate  plainly  the  absence  of  the  perineal  triangle 
and  the  close  approximation  of  rectal  and  vaginal  walls.  When 
the  woman  bears  down,  the  posterior  vaginal  wall,  and  with  it 
the  anterior  rectal  wall,  rolls  out  of  the  vulvar  orifice;  the  recto- 
cele  is  evident.  On  inspection  of  the  external  parts  the  elonga- 
tion of  the  perineum  is  seen,  the  anus  being  nearer  the  coccyx 
than  it  should  be,  and  the  skin  of  the  perineum  is  evidently  re- 


Fig.  159. — Testing  the  thickness  of  the  rectovaginal  septum  by  the  forefinger  in  the 
rectum  and  the  thumb  in  the  vagina. 

laxed.  Penrose  calls  attention  to  an  interesting  test  of  the  in- 
tegrity of  the  muscles  of  the  pelvic  floor.  If  in  an  uninjured 
woman  the  perineum  or  a  labium  is  pricked  with  a  pin,  the  bulbo- 
cavernosus  and  the  levator  ani  muscles  respond  to  the  irritation 
by  a  strong  reflex  contraction  drawing  the  anus  and  the  vulvar 
orifice  nearer  to  the  symphysis.  If  the  levator  ani  muscle  is 
lacerated,  there  is  no  response  to  external  irritation  and  no  power 
of  voluntary  contraction  ;  the  perineum  remains  flabby  and  re- 
laxed ;  the  position  of  the  anus  is  unaltered.  The  woman  gives 
the  history  that  she  cannot  stand  long  erect  or  make  much  effort 
in  the  erect  posture  without  backache,  a  feeling  of  weight,  bear- 


Injuries  of  the  Vagina  and   Pelvic  Floor         155 


Fig.  160. — Rectocele  of  moderate  dimensions. 


Fig.  161. — Rectocele  of  unusual  dimensions. 


156 


Diseases  and  Injuries  of  the  Vagina 


ing  down,  and  a  protrwsion  from  the  vulva,  which  is  usually  called 
by  the  patient  her  womb.  There  is  difficulty  in  defecation,  which 
the  woman  often  learns  to  obviate  in  part  by  pressing  back  the 
rectocele  with  her  hand  as  she  defecates.  There  is  frequently 
a  pain  on  the  top  of  the  head  or  in  the  nape  of  the  neck.  The 
general  health  deteriorates  and  the  nervous  system  displays  many 
symptoms  of  irritation  and  exhaustion,  even  to  melancholia 
with  a  suicidal  tendency. 

The  diagnosis  of  a  complete  tear  of  the  perineum  through 
the  sphincter  ani  should  always  be  made  with  comparative  ease 
in  a  careful  examination,  but  the  condition  is  not  infrequently 
overlooked  and  therefore  uncorrected.  Suits  for  malpractice  are 
frequently  based  on  this  ground. ^      There  is  almost  always,  but 


Fig.  162. — Multipara  ;  gaping  vulvar  orifice  with  rectocele  and  cystocele. 


not  invariably,  a  history  of  incontinence  of  gas  and  feces,  at 
least  when  the  bowels  are  loose.  With  the  woman  in  the  dorsal 
position,  stretching  the  labia  apart  displays  the  tear  into  the 
rectum  and  exposes  the  rectal  mucous  membrane.  The  re- 
tracted sphincter  ani  may  be  observed  lying  in  almost  a 
straight  line  across  the  posterior  margin  of  what  had  been 
the  anus,  and  two  well-marked  dimples  often  indicate  the 
position  of  its  ends.  The  skin  over  the  sphincter  posteriorly 
is  thrown  into  exaggerated  folds,  which  are  not  so  plainly 
marked  laterally,  and  of  course  are  entirely  lacking  ante- 
riorly.     A    forefinger    in    the    rectum    and    the    thumb    in    the 

^  The  author  figured  as  an  expert  witness  in  three  such  suits  in  a  single  year. 


Fig.  163. — Complete  tear  of  perineum  shortly  after  labor. 


Fig.  164. — Complete  tear  of  perineum. 
157 


Fig.  165. — Complete  tear  of  perineum. 


Fig.  166. — Complete  tear  of  perineum. 
158 


Fig.   167. — Complete  tear  of  perineum,  destruction  of  rectovaginal  septum,   vesico- 
vaginal tistula,  gangrene  of  cervix,  and  obliteration  of  the  uterine  cavity. 


Fig    168. — Complete  tear  of  perineum,  atresia  of  vagina,  cystocele,  and  prolapse  of 

the  rectum. 
159 


i6o 


Diseases  and  Injuries  of  the  Vagina 


vagina  nia}-  be  made  to  meet  within  the  vulvar  orifice,  or  rather 
within  the  common  cloaca  made  by  the  junction  of  the  vaginal 
and  rectal  orifices.  If  there  has  been  a  considerable  degree  of 
spontaneous  repair  of  the  injury  after  labor,  or  if  it  has  been 
operated  upon  without  success  in  joining  the  ends  of  the  sphinc- 
ter, the  diagnosis  of  a  laceration  and  a  consequent  separation  of 
the  muscle  is  not  so  easy.  ^  On  inspection  the  ray-like  folds  of 
mucous  membrane  and  skin  which  should  completely  surround 
the  anus  are  observed  in  exaggerated  form  posteriorly,  but  are 


Fig.  169. — Complete  tear  of  the  perineum,  with  attempt  at  spontaneous  repair. 


entirely  lacking  anteriorly,  and  are  not  well  marked  or  are  not 
seen  at  all  laterally.  The  anus  may  gape  unnaturally.  A  fore- 
finger inserted  in  the  anus  is  not  grasped  by  the  ring  muscle  as 
it  should  be.  If  the  anterior  rim  of  the  anus  is  palpated  between 
the  forefinger  internally  and  the  thumb  externally,  nothing  but 
the  thickness  of  skin  and  mucous  membrane  is  felt ;  there  is  an 
absence  of  the  band  of  muscle  about  as  thick  as  one's   little  fin- 

1  Every  year  about  half  the  author's  operations  for  complete  tear  are  performed 
on  patients  already  operated  upon  unsuccessfully  by  other  surgeons.  Figures  1 70  to 
174  are  types  of  these  cases. 


Injuries  of  the  Vagina  and   Pelvic  Floor         i6i 

ger  which  should  completely  surround  the  anus  if  the  sphincter 
is  intact.  Posteriorly  the  muscle  is  felt  somewhat  thicker  than 
normal  unless  it  has  undergone  atrophy,  running  in  an  almost 
straight  line  from  side  to  side.  The  tip  of  the  forefinger  can  be 
inserted  in  a  depression  at  either  end  of  the  muscle,  caused  by 
the  retraction  of  its  fibers  pulling  in  the  superimposed  tissues  to 
which  they  have  become  adherent.  There  is  voluntary  and 
reflex  contraction  of  the  muscle   unless  the  injury  is  an  old  one 


Fig.  170. — Unsuccessful  operation  tor  complete  tear.      Sphincter  not  joined.      Incon- 
tinence of  gas  and  feces. 


and  the  sphincter  is  atrophied  ;  but  instead  of  puckering  the 
anus  as  it  should  normally,  the  contracting  sphincter  pulls  the 
perineal  structures  on  either  side  of  the  median  line  downward 
and  inward  in  a  characteristic  and  peculiar  manner.  The  diag- 
nosis of  a  central  tear  of  the  perineum  is  made  by  inspection  and 
by  the  use  of  a  probe,  which  passes  into  the  opening  on  the  sur- 
face of  the  perineum  and  enierges  in  the  vagina. 

The  treatment  of  injuries  to  the  vagina  differs  with  the  site 


Jig.    171. — Unsuccessful  repair  of  perineum.      Rectovaginal  fistula,   indicated  by  a 

curved  needle. 


Fig.  172. — Unsuccessful  repair  of  complete  laceration  of  perineum. 

162 


Treatment  of  a  Cystocele 


163 


and  degree  of  the  laceration.  Rents  and  cuts  with  the  blades  of 
a  forceps  in  the  canal  above  the  entrance  may  be  immediately 
repaired  with  a  running  catgut  stitch  if  they  bleed  too  much. 
Later  the  cicatrices  of  these  injuries  may  have  to  be  excised,  cut, 
or  stretched.  (See  Stenosis  and  Atresia.)  It  is  convenient  to 
take  up  the  treatment  of  the  other  forms  of  injury  to  the  vaginal 
walls  and  to  the  pelvic  floor  separately. 


Fig.  173. — Unsuccessful  repair  of  complete  laceration  of  perineum. 


Treatment  of  a  Cystocele.— It  is  possible  directly  after  labor 
both  to  recognize  and  to  treat  the  injury  of  the  anterior  vaginal 
wall  that  eventually  causes  a  cystocele.  ^  Usually  the  condition 
is  overlooked  and  uncorrected.  In  the  course  of  time,  perhaps 
only  after  many  years,  the  displacement  of  the  bladder  gives 
rise  to  such  discomfort  from  difficulty  in  urination  and  decom- 
position of  residual  urine  that  the  patient  demands  relief  The 
most  satisfactory  and  the  only  treatment    certain    in  its  results 

^  See  the  author's  "Text- Book  of  Obstetrics." 


164  Diseases  and  Injuries  of  the  Vagina 


Fig.  174. — Three  unsuccessful  attempts  at  repair  of  complete  laceration  in  fourteen 
years.     The  fourth  operation  in  the  University  Hospital  was  successful. 


P"ig.  175. — Insertion  of  Gehrung's  pessary. 


Treatment  of  a  Cystocele 


165 


is  the  operative.  The  patient  may  refuse  it,  however,  or  there 
may  be  good  reasons  in  the  individual  case  for  avoiding  an  oper- 
ation. The  mechanical  support  of  a  prolapsed  bladder,  there- 
fore, must  occasionally  be  considered.  The  most  satisfactory 
of  the  pessaries  for  cystocele  is  Gehrung's.  With  this  instru- 
ment the  patient  may  often  be  made  quite  comfortable,  but  it 
is  easilv  displaced  and  there  is  a  constant  likelihood  of  ulceration 
in  the  anterior  vaginal  wall.  Moreover,  it  will  not  maintain  its 
position  unless  the  pelvic  floor  is  fairly  well  preserved. 

The  manner  of  inserting  a  Gehrung's  pessary,  which  requires 


Fig.  176. — Gehrung's  anteversion  pessary. 


Fig.  177. — Globe  pessary. 


Fig.  178. — Skene's  cystocele  pessary. 


Fig.  179. 


-Schultze's  sleigh-shaped 
pessary. 


considerable  manipulative  skill,  is  shown  in  figure  175.  After  its 
insertion  it  is  adjusted  with  the  forefinger  of  the  left  hand  so  that 
the  lower  bar  rests  above  the  symphysis  and  the  upper  bar 
beneath  and  in  front  of  the  cervix.  The  pessary  must  be  removed 
and  cleansed  at  least  once  in  four  weeks,  and  before  it^  is  rein- 
serted the  anterior  vaginal  wall  must  be  carefully  inspected,  by 
means  of  a  duck-bill  speculum  with  the  patient  in  Sims'  position, 
for  irritation  or  ulceration,  which  would  contraindicate  the  use 
of  the  support  for  two  weeks..  A  globe  pessary  supported  by  a 
napkin   or  a  T-binder,  a  Thomas'   anteversion  pessary,  a  Skene's 


i66 


Diseases  and  Injuries  of  the  Vagina 


cystocele  pessary,  or  a  Schultze's  sleigh  pessary  may  in  individual 
instances  be  more  satisfactory  than  the  Gehrung's,  but  the  latter 
is  the  more  uniformly  reliable. 

As  already  stated,  the  operative  treatment  is  preferable.  The 
ideal  operation  must  rejoin  the  torn  ends  of  the  urogenital  trigo- 
num  muscle,  remove  redundant  tissue  (the  stretched  and  relaxed 
mucosa),  and  re-establish  a  firm  connection  between  the  anterior 
vaginal  wall  and  subjacent  structures.  These  requirements  are 
best  fulfilled  by  the  operation  represented  in  figure  1 80. 

The  anterior  vaginal  sulcus  on  the  left  side  is  displayed  by  three 
bullet  forceps  making  traction  at  the  three  angles  of  the  sulcus. 
As  the  woman  lies  in  the  dorsal  position  on  the  table  the  sulcus  is 
not  easily  accessible  and  can  not  conveniently  be  denuded,  as  it 


Fig.  180. — The  author's  operation  for  cystocele. 


lies  hidden  within  the  vagina ;  but  by  fixing  one  bullet  forceps 
alongside  the  orifice  of  the  urethra,  the  other  on  the  opposite 
vaginal  wall,  and  the  third  half-way  up  the  vaginal  wall  at  the 
apex  of  the  sulcus,  the  triangular  area  involved  in  the  injury  comes 
plainly  into  view.  The  triangle  is  marked  out  with  a  knife,  and 
the  mucous  membrane  is  readily  dissected  off  by  scissors  in  one 
piece,  which  takes  but  a  minute  or  two.  The  other  side  is  treated 
in  the  same  manner.  Usually  the  tear  is  deeper  on  the  left  side 
and  may  be  confined  to  that  side.  The  sulcus  being  denuded,  the 
sutures  of  silkworm-gut  are  inserted  just  as  they  are  in  the  pos- 
terior sulci  in  an  Emmet  operation.  They  are  not  yet  united,  but 
are  clipped  temporarily  with  hemostats.  The  cervix  is  pulled 
out  of  the  vulva  and  the  rest  of  the  operation  is  performed  by 
making  an  oval  denudation  between  and  above  the  sulci  and  in- 


Treatment  of  a  Cystocele 


167 


Fig.  181. — Exposure  of  the  cystocele  by  pulling  the  cervix  uteri  outside  the  vulva  for 
the  oval  denudation  and  tier  suture  of  Martin. 


Fig.  182. — Incision  to  mark  out  the  area  of  denudation. 


i6S  Diseases  and  Injuries  of  the  Vagina 


Fig.  183. — Loosening  the  upper  margin  of  the  flap  and  catching  it  with 
tissue  forceps  or  hemostats. 


Fig.  184. — Dissecting  off  the  flap  in  one  piece  with  a  knife. 


Secondary  Perineorrhaphy  169 

serting  a  buried  continuous  tier  suture  of  catgut.  After  the 
closure  of  the  oval  denudation,  the  sulci  sutures  are  united  with 
shot. 

Stoltz's  operation  of  a  small  circular  denudation  and  a  purse- 
string  suture  around  the  edges  of  the  denuded  surface  does  not 
give  a  permanently  satisfactory  result.  The  large  oval  denuda- 
tion and  tier  suture  of  catgut  advocated  by  August  Martin  is  an 
excellent  operation,  but  it  does  not  unite  the  torn  muscles  which 
should  support  the  lower  anterior  vaginal  wall  and  the  urethra, 
and  therefore  it  is  not  always  permanently  successful. 

It  is  always  necessary  to  unite  with  the  operation  for  the 
cystocele  an  Emmet's  or  a  Hegar's  operation  to  restore  the 
pelvic  floor  and  to  contract  the  vagina,  even  though  the  latter 
may  not  appear  on  a  cursory  examination  to  be  much  injured  or 
relaxed. 

Treatment  of  Lacerations  of  the  Perineum  and  of  the  Pelvic  Floor. 
— All  lacerations  of  the  perineum  and  of  the  vaginal  sulci  should 
be  repaired  immediately  after  or  within  a  few  days  of  labor.  ^  If 
there  is  no  visible  tear,  but  a  palpable  injury  of  the  levator  ani 
muscle,  a  few  stitches  should  be  inserted  either  from  the  perineum 
by  a  large  curved  needle  with  a  wide  lateral  sweep,  through  the 
fibers  of  the  levator  ani  muscles,  or  from  the  surface  of  the  pos- 
terior vaginal  wall.  In  consequence  of  the  improved  training  in 
obstetrics  received  by  the  present  generation  of  medical  students, 
the  hope  is  justified  that  the  necessity  for  secondary  operations 
on  the  pelvic  floor  will  become  almost  as  rare  as  the  need  of  opera- 
tions for  vesicovaginal  fistulae,  which  has  enormously  decreased 
of  late  years. 

In  rare  instances  the  woman's  general  condition,  a  bruised, 
sloughing  wound,  local  infection,  or  edema  may  forbid  an  imme- 
diate perineorrhaphy,  which  must  be  postponed  for  perhaps  two 
weeks.  Performed  at  any  time  from  twenty-four  hours  to  two 
weeks  after  labor,  the  operation  is  called  intermediate.  During 
this  period,  as  a  rule,  no  denudation  is  required.  The  torn 
surfaces  are  freshened  by  scraping  with  the  sharp  edge  of  a 
knife  or  a  sharp  curst,  and  the  sutures  are  introduced  as  in  a 
primary  operation.  If  the  repair  of  the  injury  is  undertaken  more 
than  two  weeks  after  labor,  the  operation  is  called  secondary. 

Secondary  perineorrhaphy  is  performed  for  three  indications  : 
the  repair  of  a  median  tear  of  the  perineum  ;  the  repair  of  a 
perineal  tear  involving  the  sphincter  ani  and  rectum  ;  the  repair 
of  injury  to  the  levator  ani  muscle,  with  a  coincident  correction 
of  displacement  of  the  posterior  vaginal  wall  (rectocele)  and  a 


birth-can 


For  the  varieties,  appearance,  diagnosis,  and  repair  of  lacerations  of  the  lower 
canal  after  labor,  see  the  author's  "  Text-Book  of  Obstetrics." 


170  Diseases  and  Injuries  of  the  Vagina 

gaping,  relaxed,  subinvoluted  vagina.  For  each  of  these  three 
indications  a  different  operative  procedure  must  be  selected. 

Secondary  Operation  for  a  Median  Perineal  Tear. — The  labia  are 
caught  by  double  tenacula  or  bullet  forceps  at  the  upper 
margin  of  the  tear  on  a  level  with  the  lowermost  carunculse 
myrtiformes,  and  are  stretched  apart.  The  triangular  space  to 
be  denuded,  with  the  base  above  and  the  apex  below  where  the 
tear  terminates,  is  thus  displayed.  One  blade  of  a  sharp-pointed 
scissors  is  inserted  under  the  skin  at  the  lower  angle  of  the  tear, 
and  is  run  up  the  mucocutaneous  margin,  as  one  would  slit  a  piece 
of  muslin,  to  the  bullet  forceps  on  one  side.  A  similar  cut  is 
made  upon  the  other  side.  The  two  lines  thus  formed  are 
joined  above  by  a  straight  transverse  incision.  The  surface  to  be 
denuded,  being  thus  isolated,  is  dissected  off  in  one  piece  by 
small  blunt-pointed  scissors  curved  on  the  flat,  or  is  taken  off  in 
strips  if  the  operator  prefers  the  slower  and  more  tedious 
method.  The  raw  surfaces  are  then  brought  together  by  inter- 
rupted silkworm-gut  sutures  running  straight  across  the  wound, 
buried  all  the  way,  entering  and  emerging  upon  the  skin  about 
an  eighth  of  an  inch  from  the  raw  surfaces.  The  stitches  are 
knotted  or  shotted.  The  former  method  avoids  the  pits  in  the 
line  of  the  wound  which  usually  result  from  the  use  of  a  shot, 
but  the  latter  secures  a  neater  apposition  and  is  quicker.  As 
one  important  object  of  this  operation  is  to  rejoin  the  lacerated 
transversus  perinei  muscle,  curved  needles  should  be  used  and 
the  suture  should  take  a  circular  sweep  out  into  the  tissues  on 
either  side  of  the  wound  so  as  to  catch  the  retracted  ends  of 
muscle.  This  principle  applies  also,  and  with  greater  force,  to 
the  repair  of  the  other  more  important  muscles  of  the  pelvic 
floor  that  are  injured  in  labor,  the  levator  and  the  sphincter  ani 
muscles. 

Secondary  Perineorrhaphy  for  a  Complete  Tear  of  the  Perineum 
Involving  the  Sphincter  Ani  Muscle  and  the  Rectovaginal  Septum, 
— Before  undertaking  an  operation  to  unite  a  torn  sphincter,  it  is 
essential  to  thoroughly  evacuate  the  intestines,  especially  the 
lower  bowel.  The  preparation  of  the  patient  begins  two  days 
before  the  operation.  On  the  first  night  two  drams  of  Rochelle's 
salts  are  given  in  a  tumbler  of  water.  On  the  second,  the  night 
before  the  operation,  a  half  ounce  of  Epsom  salts  in  a  tumbler  of 
water  is  administered.  On  the  morning  of  the  operation  an 
enema  of  soapsuds  (i  pint)  and  turpentine  (i  dram)  is  given, 
followed  by  repeated  rectal  injections  of  a  pint  to  a  quart  of  water 
until  no  more  fecal  matter  is  brought  away.  It  requires  ordina- 
rily at  least  six  such  injections  to  remove  all  the  contents  of  the 
lower  bowel  so  as  to  prevent  an  evacuation  of  feces  during  the 


Operation   for  Complete  Tear 


171 


operation,  which    might   infect  the  wound   and   the  sutures  and 
prevent  primary  union. 

The  first  step  in  the  operation  is  the  stretching  of  the 
sphincter,  to  temporarily  paralyze  it  and  so  to  prevent  the  spas- 
modic contraction  of  the  muscle,  which  might  interfere  with  the 
union  of  its  ends.  Moreover,  the  relaxation  of  the  muscle 
permits  evacuation  of  the  bowels  after  the  operation  with  the 
least  strain  upon  the  sphincter.  With  the  hands  protected  by 
rubber  gloves  the  operator  seizes  both  ends  of  the  sphincter  ani 
between  the  forefingers  in  the  rectum  and  the  thumbs  externally 
and  stretches  it  forcibly  for  about  a  minute.  The  gloves  are 
changed  or  are  well  rinsed  in  bichlorid  solution.      Bullet  forceps 


A  B 

Fig.    185. — A,  Incision  for  complete  tear  operation  ;    B,  denudation  of   the  tissues 
over  the  ends  of  the  sphincter. 


are  fastened  to  the  labia  on  each  side  at  the  level  of  the  lower  carun- 
culae  myrtiformes,  and  the  labia  are  pulled  apart  by  assistants.  A 
strand  of  silkworm-gut  is  fastened  to  the  vaginal  mucous  mem- 
brane at  the  apex  of  the  tear  in  the  rectovaginal  septum,  and  is 
tied  in  a  loop  by  a  single  knot.  This  guide  suture  is  lifted 
toward  the  urethra.  The  rectovaginal  septum  is  now  slit  with  a 
knife  transversely  after  the  flap-splitting  method,  and  the  incision 
is  then  carried  downward  over  the  ends  of  the  sphincter,  which 
are  marked  by  easily  perceptible  and  palpable  dimples.  The 
knife  is  then  drawn  along  the  mucocutaneous  margin  upward  on 
both  sides  to  the  bullet  forceps.  From  these  points  the  area  to  be 
denuded  is  marked  with  small  sharp-pointed  scissors  and  differs 


172 


Diseases  and  Injuries  of  the  Vagina 


as  the  perineal  tear  is  simply  median  or  extends  up  the  vaginal 
sulci.  In  the  latter  case  the  denudation  in  the  vagina  is  made 
as  for  an  Emmet's  or  a  Hegar's  operation,  subsequently  to  be 
described.  After  marking  off  the  area  to  be  denuded,  the  flap 
made  by  the  first  incision  is  freed  b\'  a  dissection  upward  under 
the  vaginal  mucous  membrane  and  inward  from  the  labial  and 
perineal  surfaces.  The  outer  edges  of  this  flap  are  removed,  but 
the  tissue  in  the  median  line  is  spared  as  much  as  possible,  and 
care  is  exercised  not  to  excise  rectal  mucous  membrane  on  ac- 
count of  troublesome  hemorrhage  from  the  hemorrhoidal  veins. 
The  dissection  described  lays  bare  the  ends  of  the  sphincter.      To 

insure  their  complete  expo- 
sure, the  skin  over  the  lower 
margins  of  their  ends  is 
seized  with  a  rat-tooth  for- 
ceps and  snipped  off  with 
scissors.  The  cicatricial  tis- 
sue over  the  ends  of  the 
muscle  is  also  seized  with  a 
rat-tooth  forceps,  lifted  up 
and  cut  away  with  scissors 
curved  on  the  flat,  just 
enough  tissue  being  removed 
to  expose  the  raw  muscle 
and  not  to  shorten  it. 

If  the  tear  runs  up  the 
rectovaginal  septum,  the  first 
sutures  of  silkworm-gut  are 
inserted  from  the  rectum, 
half-way  through  the  sep- 
tum on  both  sides  and  back 
again  into  the  rectum,  where  they  are  knotted.  From  two  to 
five  are  required.  Before  inserting  the  sphincter  sutures  the  ends 
of  the  muscle  are  seized  with  tenacula,  pulled  out  of  the  depres- 
sions in  which  they  lie,  and  approximated  in  the  median  line. 
The  sutures  through  the  sphincter,  two  in  number,  of  silkworm- 
gut,  are  inserted  from  the  rectal  side,  with  a  broad  sweep  of  a 
curved  needle  deep  into  the  substance  of  the  muscle,  which  they 
completely  traverse,  crossing  the  wound,  and  emerging  in  what 
will  be  the  rectal  surface  of  the  anus  when  the  sphincter  is  joined. 
The  sutures  through  the  sphincter  are  tightly  knotted  with  a 
triple  knot.  After  inserting  the  rectal  and  sphincter  sutures,  a 
long  barrier  stitch  is  inserted,  beginning  just  above  the  united 
sphincter,  running  up  the  rectovaginal  septum  to  the  upper 
angle  of  the  tear  in   it,  crossing  the  wound,  coming   down   the 


Fig.  i86. — Pulling  the  ends  of  the 
sphincter  together  with  large  tenacula, 
while  deep  sutures  are  inserted  through 
them  from  the  rectum. 


Operation  for  Complete  Tear  173 

otlier  side,  and  emerging  opposite  the  point  of  first  insertion  on 
the  perineum,  where  it  is  fastened  b\'  a  shot.  The  remainder  of 
the  operation  is  performed  as  one  for  a  median  perineal  tear  or 
tlie  Emmet  or  Hegar  operation  for  injury  to  the  pelvic  floor.  ^ 

Another  plan  of  operating  which  avoids  the  troublesome 
necessity  of  removing  the  rectal  stitches  after  the  wound  has 
healed  is  as  follows  :  After  completing  the  denudation  of  the 
rectovaginal  septum,  the  ends  of  the  sphincter,  and  the  site  of  the 
vaginal  injury,  close-set  interrupted  sutures  are  inserted  from  the 
vagina,  through  the  depth  of  the  wound  to,  but  not  through, 
the  rectal  mucous  membrane.  The  anterior  rectal  wall  may  be 
pulled  down,  after  the  flap-splitting  dissection,  until  it  lies  under 
the  joined  ends  of  the  sphincter,  thus  protecting  the  wound  from 
fecal  evacuations  during  convalescence.  Two  silkworm-gut  sutures 
are  inserted  through  the  sphincter,  with  the  precautions  already  de- 
scribed, the  stitches  entering  and  emerging  on  the  skin  surface  of 
the  anus.  Before  uniting  any  of  these  stitches,  each  one  of 
which  is  held  in  the  grip  of  a  hemostat,  the  whole  raw  surface 
between  the  vagina  and  rectum  is  whipped  together  with  a  run- 
ning double  tier  stitch  of  formalin  catgut,  starting  at  the  upper 
angle  of  the  tear  in  the  rectovaginal  septum,  running  down  the 
lower  part  of  the  wound,  just  avoiding  the  rectal  mucous  mem- 
brane, taking  two  turns  through  the  ends  of  the  sphincter, 
returning  along  the  upper  part  of  the  wound,  and  ending  oppo- 
site the  point  of  first  insertion  in  the  vagina.  Only  one  knot, 
therefore,  is  required  at  the  upper  angle  of  the  wound  on  the 
vaginal  surface.  The  interrupted  sutures  are  then  united  with 
shot  burying  the  catgut  stitch  and  uniting  the  whole  extent  of 
denuded  surfaces  between  the  vagina  and  rectum.  The  vagina 
is  packed  lightly  with  a  strip  of  iodoform  gauze,  which  is 
removed  in  twenty-four  hours.  No  vaginal  douches  are  given, 
as  they  are  unnecessary  and  may  be  harmful.  The  patient  is 
allowed  to  pass  water  if  she  can.  If  the  catheter  is  used,  it  is 
discontinued  as  soon  as  possible.  After  urination  the  vulva  is 
irrigated  by  sterile  water  poured  over  it  out  of  a  pitcher,  with  the 
patient  on  a  bedpan. 

In  the  after-care  of  the  patient  the  diet  should  consist  of  such 
articles  as  will  not  leave  much  detritus  in  the  bowel ;  soups,  tea, 
beer,  junket,  wine  jelly,  given  in  small  quantities  every  three 
hours.  As  soon  as  the  patient's  stomach  has  become  tolerant 
after  the  anesthetic,  the  administration   of  a  laxative  should  be 

^  The  author  has  averaged  from  four  to  twenty  operations  for  complete  tear  every 
year  for  the  last  fifteen  years  with  uniform  success  by  this  technic.  He  hesitates, 
therefore,  to  adopt  any  of  the  recent  modifications  proposed,  which  utilize  catgut 
more  estensively. 


174  Diseases  and  Injuries  of  the  Vagina 

begun,  so  that  there  may  be  a  Hquid  movement  of  the  bowels 
within  twenty-four  or  thirty-six  hours  of  the  operation.  There- 
after two  or  three  such  movements  daily  must  be  secured,  for  at 
least  two  weeks,  and  the  fecal  evacuations  must  be  kept  soft  for 
six  weeks  or  more  after  the  operation.  A  hard  mass  of  feces 
has  torn  a  united  sphincter  apart  more  than  three  weeks  after  an 
operation  for  a  complete  tear.  The  best  laxative  for  the  first  two 
weeks  is  a  tumbler  of  Carlsbad  water  and  a  teaspoonful  of 
Sprudel  salts  morning  and  evening.  A  third  dose  in  the  middle 
of  the  day  may  be  required.  After  the  second  week  any  of  the 
simpler  laxatives  suffice,  such  as  licorice  powder,  syrup  of  senna, 
cascara,  or  weak  solution  of  Rochelle's  salts.  The  prolonged 
use  of  Epsom  salts  is  productive  of  enteritis  and  proctitis,  so  that 
they  are  unavailable.^ 

The  stitches  are  removed  on  the  sixteenth  day.  If  sutures 
have  been  required  in  the  rectovaginal  septum  and  have  been 
knotted  in  the  rectum,  they  are  removed  with  the  patient  in  the 
knee-chest  posture,  through  a  narrow  bivalve  rectal  speculum 
and  with  the  aid  of  an  electric  headhght.  Great  care  must  be 
exercised  not  to  cut  off  both  ends,  as  the  knots  are  usually  buried 
in  the  mucous  membrane  and  it  is  a  troublesome  task  to  cut  and 
remove  the  stitch  in  the  confined  area  in  which  one  must  work. 

The  patient  is  allowed  to  sit  up  at  the  end  of  three  weeks  and 
is  cautioned  to  keep  the  bowels  softened  by  laxatives  for  weeks 
to  come. 

If  the  sphincter  has  been  torn  for  years  it  undergoes  atrophy 
and  may  be  incapable  of  vigorous  contraction  even  if  it  is  firmly 
united,  so  that  in  spite  of  a  successful  operation  there  is  partial 
incontinence  of  gas  and  feces.  The  application  every  other  day 
for  three  months  of  a  faradic  current  of  electricity  to  the  sphinc- 
ter has  restored  its  contractile  power  in  two  cases  under  the 
author's  care  in  which  the  muscle  in  one  case  was  repaired  four- 
teen years  after  the  original  injury  and  after  three  unsuccessful 
attempts  had  been  made  by  other  operators  to  join  its  ends,  and 
in  another  after  ten  years.  In  reoperating  upon  a  case  of  com- 
plete tear  after  an  unsuccessful  attempt  at  repair,  ^  there  must 
be  some  modification  of  the  technic  just  described.  In  almost 
all  such  cases  the  perineum  has  been    restored,  but  the  ends  of 

'  In  the  case  of  a  young  girl  (Fig.  167)  obstinately  constipated  and  with  such  an 
irritable  stomach  that  laxatives  were  not  tolerated,  the  author  adopted  with  success  a. 
suggestion  of  Leopold,  to  keep  the  bowels  locked  for  sixteen  days,  on  a  meager  diet, 
and  then  to  open  them  with  calomel  and  salines  and  by  oil  and  ox-gall  enemata. 
This  plan  is  occasionally  convenient,  but  is  not  to  be  generally  recommended. 

2  The  principles  that  should  govern  these  operations  can  not  be  generally  well 
understood,  for  every  year  the  author  has  two  to  eight  operations  to  perform  on  women 
who  have  already  been  subjected  to  one  or  more  unsuccessful  attempts  to  repair  a  torn 
sphincter. 


Operation  for  Complete  Tear 


175 


the  sphincter  are  separated  a  half  inch  or  more,  and  there  is  com- 
plete incontinence.  Considerable  tissue  has  usually  been  sacri- 
ficed in  the  former  operation,  and  there  is  none  to  spare,  so  that 
the  flap-splitting  principle  must  be  utilized  to  the  full.  The 
sphincter  is  stretched  as  in  all  these  operations.  A  straight 
incision  is  made  in  the  median  line  of  the  perineum,  branching  off 
outward  and  downward  in  the  form  of  an  inverted  Y.  The  skin 
is  turned  back  from  the  lines  of  incision  so  that  the  retracted 
ends  of  the  sphincter  are  freely  exposed.  They  are  superficially 
denuded,  caught  by  tenacula,  and  brought  together  in  the  median 
line.  Two  sutures  of  silkworm-gut  on  a  curved  needle  are  in- 
serted from  the  skin  surface  of  the  anus,  carried  with   a  broad 


Fig.  187. — A,  Exposure  of  the  ends  of  the  sphincter  in  a  reoperation  for  complete 
tear  ;  B,  catching  the  ends  of  the  sphincter  with  tenacula. 


sweep  deeply  into  the  two  halves  of  the  muscle  and  are  united 
with  shot.  The  perineal  wound  is  brought  together  with  inter- 
rupted sutures  of  silkworm-gut.  In  cases  of  stretched  skin 
perineum  and  widely  separated  ends  of  the  sphincter  after  an  un- 
successful operation,  the  incision  may  be  made  as  represented  in 
figure  187. 

A  common  cause  of  comparative  failure  after  the  operation 
for  complete  tear  is  the  persistence  of  a  rectovaginal  fistula  just 
above  the  united  sphincter  muscle.  This  complication  most  fre- 
quently occurs  in  the  hands  of  those  operators  who  depend  upon 
Emmet's  triangular  stitch  to  join  the  sphincter,  which  is  not  to 


1/6 


Diseases  and  Injuries  of  the  Vagina 


be  recommended.  The  most  satisfactory  treatment  is  to  cut  the 
sphincter  again  with  one  blade  of  a  scissors  in  the  fistula  and  the 
other  externally,  to  curet  the  fistulous  tract,  and  then  to  join  the 
ends  of  the  sphincter  as  in  the  operation  just  described. 

Secondary  Perineorrhaphy  for  Injury  to  the  Levator  Ani  Muscle, 
Rectocele,  Overstretching  and  Subinvolution  of  the  Vagina. — Lac- 
erations of  the  vaginal  sulci,  involving  the  levator  ani  mus- 
cle and  resulting  eventually  in  a  rectocele,  are  best  repaired 
in  the  vast  majority  of  cases  by  the  Emmet  operation.      Many 


Fig.  l88. — Photograph  of  result  of  operation  on  patient  represented  in  figure  167.^ 

other  operations  have  been  proposed  and  are  practised  for 
injuries  to  the  pelvic  floor  and  to  the  vagina.  Bischoff' s  butter- 
fly-wing denudation  and  vaginal  flap,  adopted  and  modified  by 
Goodell,  Tait's  flap-splitting  method,  Martin's  parallel  denudation 
of  the  sulci  in  two  narrow  strips,  have  had  and  still  have  their 
advocates,  but  the  author  for  many  years  has  employed  but  two 
operations  for  restoring  the  pelvic  floor  and  narrowing  the  vagina 
— those  devised  by  Emmet  and  by  Hegar.  Thomas  Addis 
'  Figs.  18S,  189,  190  should  be  contrasted  with  Figs.  170-174. 


Emmet's  Operation 


177 


Kmmet  ^  in  October,  188 1,  performed  the  operation  for  injury  to 
the  pelvic  floor  which  bears  his  name.  It  was  the  most  notable 
contribution  to  the  plastic  surgery  of  the  female  pelvis,  and  has 
proved  a  boon  of  incalculable  value  to  surgeons  and  their 
patients  the  world  over.  By  the  triangular  denudation  of  the 
sulci  and  of  the  rectocele  below  its  crest ;  the  insertion  of  the 
stitches  in  the  sulci  from  above  dov/nward  so  that  they  pull  back 
the  posterior  wall  of  the  vagina  as  they  unite  the  torn  fibers  of 
the  levator  ani  muscle  ;   by  the  insertion  of  the  "  crown  suture" 


Fig.  189. — Photograph  of  result  of  successful  operation  for  complete  tear. 


which  lifts  the  end  of  the  posterior  column  of  the  vagina  to  its  nor- 
mal position,  unites  the  ends  of  the  bulbocavernosus  muscles,  and 
restores  the  normal  caUber  of  the  vulvar  orifice,  the  most  perfect 
correction  of  a  common  and  serious  injury  of  labor  is  achieved. 
In  a  small  proportion  of  cases,  however,  the  Hegar  operation  is 
preferable.  If  the  posterior  vaginal  wall  is  stripped  off  its  subja- 
cent attachment  as  the  anterior  wall  is  in  a  cystocele,  and  projects 
from  the  vulva  without  an  accompanying  rectocele  ;  if  the  vagina 
is  very  much  dilated  and  subinvoluted  with  a  widely  gaping  vul- 

^  "  Principles  and  Practice  of  Gynecology,"  3d.  ed.,  Philadelphia,  1884. 


1/8 


Diseases  and  Injuries  of  the  Vagina 


var  orifice,  and  if  there  is  a  decided  prolapsus  uteri,  the  triangular 
denudation  of  Hegar,  running  far  up  the  posterior  wall  of  the 
v^agina,  gives  a  firmer  support,  more  radically  contracts  the 
vaginal  canal,  and  promises  a  surer  retention  of  a  prolapsed 
uterus  than  does  the  Emmet  operation,  with  a  tongue  of  the 
original   overstretched  and   relaxed  vaginal   mucous  membrane 


Fig.  190. — Result  of  repair  in  complete  tear  (young  girl). 


intervening  between  the  sutures  in  the  denuded  and  approximated 
surfaces  of  the  two  sulci. 

The  Emmet  operation  is  performed  as  follows  :  Two  bullet 
forceps  are  fastened  to  the  labia  majora  at  the  level  of  the  lower- 
most carunculse  myrtiformes.  A  guide  suture  is  passed  through 
the  mucosa  of  the  posterior  vaginal  wall  at  the  crest  of  the  rec- 
tocele.  The  bullet  forceps  and  the  point  of  insertion  of  the 
guide  stitch  should  meet  just  below  the  urethra,  when  the  two 


Emmet's  Operation 


179 


former  are  approximated  and  the  latter  is  lifted  directly  upward 
(Fig.  192).  The  bullet  forceps  on  one  side  is  pulled  outward  and 
downward  and  the  guide  suture  is  pulled  downward  and  to  the 


Fig.  191. — Fixing  the  three  points  as  guides  in  the  operation  with  bullet  forceps  and 

a  guide  suture. 


Fig.  192. — The  Emmet  operation  :  a,  Approximation  of  the  upper  edges  of  the  peri- 
neal tear  and  the  crest  of  the  rectocele  ;  b,  displaying  the  left  sulcus. 


opposite  side.      The  injured  sulcus  is  displayed  and  the  corruga- 
tions   of   mucous    membrane    meet   above    at    the    apex  of  the 


I  So 


Diseases  and  Injuries  of  the  Vagina 


original  laceration  showing  the  extent  of  the  injury.  One  point 
of  a  sharp-pointed  straight-bladed  scissors  is  inserted  at  the  bul- 
let forceps  and  run  up  the  mucosa  of  the  sulcus  to  the  apex  of 
the  tear ;  the  scissors  is  similarly  inserted  at  the  guide  stitch  and 


Fig.  193. — Marking  off  the  area  to  be  denuded  with  scissors. 


Fig.  194. — Flap  dissected  off  with  scissors  in  the  left  sulcus. 


the  mucosa  is  slit  until  the  two  incisions  meet  (Fig.  193).  The 
triangle  thus  mapped  out  is  dissected  off  in  one  piece  by  blunt- 
pointed  scissors  curved  on  the  flat.  The  same  dissection  is  made 
on  the  opposite  side.      The  two  forceps  are  then  pulled  apart  and 


Emmet's  Operation 


i«i 


the  guide  stitch  is  held  up  in  the  median  hne:  A  third  triangle  of 
linden uded  mucosa  appears  in  the  middle  line  which  is  taken  off  in 
one  piece.  The  denudation  of  an  Emmet's  operation  may  thus 
be  completed  in  a  few  minutes.      It  can  be  done  in  a  third  of  the 


Fig-  195- — Cutting  off  the  flap  at  its  base. 


Fig.  196. — Both  sulci  denuded. 


time  required  by  an  operator  who  takes  off  the  mucous  mem- 
brane strip  by  strip. 

The   stitches   in   the  sulci  are  inserted  by  the  Emmet  needle 
and  should  be  of  silkworm-gut  throughout.      Catgut  is  too  unre- 


1 82  Diseases  and  Injuries  of  the  Vagina 


Fig-  197- — Dissecting  and  removing  the  third  triangular  flap  from  the  crest  of  the 
rectocele  to  the  base  of  the  perineal  tear. 


Fig.  198.  —  Sutures  inserted  and  held  by  hemostats. 


Emmet's  Operation  183 

liable  in  the  vagina.  Firm  and  permanent  apposition  of  the  in- 
jured muscle  can  not  always  be  obtained  by  it.  In  inserting  the 
needle  at  the  apex  of  the  denudation  the  point  should  be  directed 
downward  and  inward  so  that  it  emerges  at  the  mid-line  of  the 
sulcus  considerably  below  the  point  of  insertion  in  the  mucosa  ; 
it  is  reinserted  and  emerges  opposite  the  point  of  first  inser- 
tion. Care  should  be  taken  to  carry  the  needle  point  deep  into 
the  tissues  laterally,  by  a  turn  of  the  wrist  so  as  to  catch  the 
fibers  of  the  torn  and  retracted  levator  ani  muscle.  Three  to 
five  sutures  are  usually  required  in  each  sulcus.  After  their  in- 
sertion the  "  crown  stitch"   is  placed  with  a  large  curved  needle 


Fig.  199. — Junction  of  the  perineal  sutures  after  the  sulci  sutures  have  been  shotted. 


by  transfixing  the  raw  surface  of  the  perineum  proper  on  one 
side,  about  a  quarter  of  an  inch  below  the  bullet  forceps,  the 
denuded  crest  of  the  rectocele  just  under  the  guide  stitch  and 
the  opposite  side  of  the  denuded  perineum.  If  there  has  been  a 
tear  of  the  perineal  center,  the  rest  of  the  perineum  below  the 
crown  stitch  is  united  b)^  interrupted  sutures  inserted  with  a  large 
curved  needle.  After  all  the  sutures  are  united  by  perforated 
shot,  the  raw  surfaces  just  above  the  crown  suture  (Fig.  199)  are 
joined,  thus  forming  a  posterior  commissure,  a  fossa  navicularis, 
and  approximating  the  labia.  By  this  modification,  the  gaping 
vulva,    which    is    the    reproach    and    only    disadvantage    of   an 


Fig.  200. — The  denudation  for  a  Hegar's  operation. 


Fig.  201. — Tlie  perineal  sutures  in  a  Hegar's  operation. 
184 


New-growths  of  the  Vagina  185 

Emmet's  operation,  is  avoided.  The  Hegar's  operation  is  per- 
formed as  follows :  The  labia  are  pulled  apart  as  in  Emmet's 
operation  by  bullet  forceps;  a  guide  suture  is  placed  as  high  in 
the  middle  line  of  the  posterior  vaginal  wall  as  the  denudation  is 
to  be  carried,  sometimes  just  below  the  cervix.  As  the  forceps 
are  pulled  apart  and  the  suture  is  lifted  upward,  a  triangular 
space  is  displayed,  which  is  marked  out  by  a  knife.  The  flap  is 
dissected  off  with  scissors.  The  denuded  surfaces  are  united  by 
interrupted  vaginal  sutures  inserted  with  a  large  curved  needle. 
The  first  two  or  three  upper  sutures  may  be  of  catgut  because 
there  is  no  tension  on  them.  The  lower  sutures  should  be  of  silk- 
worm-gut. A  larger  number  of  perineal  sutures  are  required  in 
the  Hegar  than  in  the  Emmet  operation. 

The  two  most  important  displacements  of  the  vagina,  rectocele 
and  cystocele,  have  been  described.  A  complete  inversion  of  the 
vagina  usually  accompanies  a  prolapse  of  the  uterus  or  the 
descent  of  the  cervix  by  supravaginal  elongation.  It  will  be  con- 
sidered, therefore,  in  connection  with  these  displacements  of  the 
uterus.  In  one  case  of  the  author's  there  was  a  complete  inversion 
of  the  vagina  after  a  panhysterectomy  in  an  old  woman  who  had 
before  operation  a  remarkable  elongation  of  the  supravaginal 
portion  of  the  cervix.  It  was  permanently  cured  by  a  Hegar's 
posterior  colporrhaphy  and  an  extensive  anterior  colporrhaphy 
with  tier  sutures,  reducing  the  vagina  to  an  extremely  narrow 
canal.  A  complete  excision  of  the  inverted  vagina  in  such  a 
case,  with  entire  closure  of  the  canal  above  the  urethral  orifice, 
would  perhaps  have  been  the  surer  method,  and  would  be  the 
author's  choice  in  another  case. 

New=growths  of  the  Vagina. — Cysts  are  not  uncommon. 
They  are  usually  small,  though  they  have  reached  the  size  of  a 
fetal  head.  They  are  commonly  single  and  are  unilocular,  but 
multiple  cysts  are  reported,  and  septa  or  the  remains  of  septa 
have  been  observed  in  their  interior.  The  tumors  are  as  a  rule 
sessile,  but  if  they  attain  a  considerable  size  and  grow  toward  the 
vulvar  orifice  from  which  they  project  they  may  be  pedunculated. 
The  vaginal  mucous  membrane  over  them  is  normal  and  mov- 
able, but  may  become  atrophic  from  pressure.  The  rate  of 
growth  in  a  vaginal  cyst  is  very  slow  ;  after  reaching  a  moderate 
size  it  is  apt  to  remain  stationary.  Its  origin  is  often  inexplicable, 
but  it  may  be  traced  to  glandular  structures  abnormally  present 
in  the  vaginal  mucous  membrane  from  embryonal  existence  ;  to 
an  accumulation  of  fluid  in  the  remains  of  the  Wolffian  bodies, 
Gartner's  ducts,  in  the  lateral  vaults  of  the  vagina  ;  to  parovarian 
cysts  growing  downward  and  inward  toward  the  base  of  the 
broad  ligament ;  to  epithelial  structures  implanted  in  the  vaginal 


Fig.  202. — Vaginal  cyst. 


Fig.  203. — Vaginal  cyst. 


Fibromata  of  the  Vagina  187 

wall  by  traumatism  in  childbirth  or  by  an  operation  ;  to  a  uni- 
lateral development  of  the  vagina  from  one  Miiller's  duct  while 
the  other  one  produces  a  blind  tube  of  narrow  caliber  alongside 
of  it,  and  to  an  encysted  interstitial  hemorrhage.  The  cyst  may 
be  a  dermoid,  which  is  occasionally  found  between  the  rectum 
and  vagina,  or  a  h-mph-cyst,  which  occurs  an}'where  under  mu- 
cous or  cutaneous  surfaces.  The  investing  membrane  of  a  vagi- 
nal cyst  is  fibrous  in  character,  often  containing  unstriped  muscle- 
fibers.  The  interior  of  the  cyst  is  lined  with  epithelium  of  various 
kinds, — squamous,  cuboidal,  and  columnar, — the  three  types 
being  observed  sometimes  in  a  single  tumor.  Ordinarily  the 
cyst  causes  no  symptoms,  unless  its  size  is  greater  than  common, 
when  it  may  produce  irritation  of  the  vagina,  leukorrhea,  a  sense 
of  weight  and  bearing  down,  dysuria,  and  dyspareunia. 

The  treatment  of  a  vaginal  cyst  is  its  evacuation  and  its 
enucleation,  if  possible.  In  order  to  facilitate  the  latter  pro- 
cedure, it  has  been  suggested  to  fill  the  evacuated  tumor  with 
melted  parafifin  (Pozzi),  which  is  solidified  by  the  application  of 
ice.  Schroeder  proposed  the  removal  of  as  much  of  the  tumor 
as  could  easily  be  cut  away,  and  the  junction  of  the  lining  mem- 
brane of  the  remainder  of  the  cyst  with  the  vaginal  mucous 
membrane,  the  former  being  exfoliated  and  replaced  by  vaginal 
epithelium  or  converted  eventually  into  normal  vaginal  mucous 
membrane.  If  the  tumor  is  enucleated  easily  and  its  bed  is 
shallow,  the  vaginal  mucous  membrane  is  united  over  it  by 
sutures  after  whatever  hemostasis  is  required.  If  the  cavity  left 
by  the  tumor  is  of  considerable  depth,  it  should  be  packed  with 
gauze  until  it  is  obliterated  by  granulation. 

Fibromata  of  the  vagina  are  rare.  ^  They  are  usually  of  small 
size  and  situated  on  the  anterior  vaginal  wall.  In  the  poste- 
rior vaginal  vault  the  tumor  may  be  an  adenomyoma,  derived 
from  a  Wolffian  body.  Their  rate  of  growth  is  very  slow,  and 
after  reaching  a  moderate  size  they  remain  stationary.  A  fibroid 
of  the  vagina,  however,  weighing  two  pounds  has  been  reported. 
They  are  sessile  in  form,  as  a  rule.  Histologically  they  are 
like  fibroids  of  the  uterus,  but  contain  less  muscular  tissue. 

They  may  give  rise  to  no  symptoms  at  all  if  moderate  in 
size,  but  had  best  be  removed  on  account  of  the  bare  possibility 
of  malignant  degeneration.  The  enucleation  of  the  tumor  pre- 
sents no  difficulties,  and  its  removal  is  all  the  easier  if  it  is  pe- 
dunculated, as  it  sometimes  is  (fibroid  polyp  of  the  vagina),  the 
pedicle  being  transfixed  and  ligated  with  catgut  and  the  polyp 
then  cut  away. 

1  Smith  reported  to  the  Chicago  Gynecological  Society,  November,  1901,  loo 
cases  from  literature  and  one  of  his  own  ("  Amer.  Jour.  Obstet.,"  Feb.,  1902). 


i88 


Diseases  and  Injuries  of  the  Vagina 


Sarcoma  of  the  vagina  is  rare.  It  occurs  at  any  age,  but  is 
usually  found  in  women  under  forty.  It  has  appeared  in  early 
infancy  and  childhood  and  may  be  congenital.      In  children  the 


Fig.  204. — Fibiomyoma  of  posterior  vaginal  vault. 


Fig.  205. — Fibroid  polyp  from  vagina  :  e.  Squamous  epithelium  ;  c.t,  fibrous  tis- 
sue ;  V,  blood-vessel  ;  i,  area  of  inflammation  and  round-cell  infiltration  (McConnell 
and  J.  C.  Hirst). 


tumor  springs  from  the  anterior  vaginal  wall,  is  bright  or  dark  red 
in  color,  and  polypoid  in  form.  The  bladder  is  soon  involved, 
and  secondary  symptoms  due  to  infection  and  pressure  upon  the 


Carcinoma  of  the  Vagina 


189 


urinary  tract  appear.  In  adults  the  tumor  is  rounded  in  form, 
with  a  broad  base.  It  is  usually  found  upon  the  anterior  vaginal 
wall  and  at  its  lower  third.  The  mucous  membrane  over  the 
tumor  is  preserved  until  comparatively  late  in  the  history  of  the 
growth,  when  ulceration  occurs.  Occasionally  there  is  a  diffuse 
sarcomatous  infiltration  of  the  submucous  connective  tissue  in- 
stead of  a  circumscribed  tumor.  The  urinary  tract  is  apt  to  be 
invaded,  metastases  to  distant  organs  are  the  rule,  and  recurrence 
of  the  tumor  if  it  is  extirpated  is  almost  invariable. 

Carcinoma  of  the  vagina  is  usually  an  extension  of  the  same 
disease  from  the  cervix  uteri.  It  occurs  also  as  a  metastasis 
from  the  ovary  and  as  an  implantation  metastasis  from  the  corpus 


Fig.    206. — Malignant   tubular   adenoma  of  rectum   projecting  into   the  vagina   and 

breaking  down. 


uteri.  The  author  has  seen  a  carcinomatous  tumor  projecting 
from  the  posterior  vaginal  wall  that  originated  in  a  malignant  tubu- 
lar adenoma  of  the  rectal  mucous  membrane  growing  forward  to- 
ward and  into  the  vagina  and  scarcely  encroaching  upon  the  rectum 
at  all.  Primary  carcinoma  of  the  vagina  is  rare.  ^  It  is  almost 
always  an  epithelioma.  Its  favorite  seat  is  the  posterior  vaginal 
vault.  The  etiology  is  obscure.  The  irritation  from  the  pro- 
longed use  of  a  pessary  may  be  accountable  for  it.  Neugebauer 
has  collected  eight  such  cases.  The  growth  projects  as  an  ex- 
crescence from  the  vaginal  mucous  membrane  with  an  ulcerated 

^  One  hundred  and  fifty-five  cases  have  been  collected  ( "  Jahresbericht  ii.  d. 
Fortschr.  a.  d.  Gebiet  d.  Geb.  u.  Gyn.,"  vol.  xv ;  also  R.  Williams,  "  N.  Y.  Med. 
Record,"  No.  30,  1902). 


190  Diseases  and  Injuries  of  the  Vagina 

surface,  surrounded  by  an  infiltrated  area  in  which  secondary- 
nodules  soon  appear.  Carcinomatous  infiltration  of  the  vaginal 
mucous  membrane  may  be  seen  occasionally  encircling  the  canal 
in  the  form  of  a  ring. 

It  may  require  a  microscopical  examination  to  differentiate 
sarcoma  from  a  fibroma  and  carcinoma  from  tuberculosis,  condy- 
lomata and  syphilis. 

The  treatment  of  sarcoma  and  carcinoma  of  the  vagina  is  pal- 
liative and  radical.  The  former  is  the  only  justifiable  treatment 
if  the  growth  is  secondary  or  metastatic,  if  it  is  too  extensive  for 
complete  removal,  or  has  already  produced  metastases  elsewhere. 
The  treatment  in  such  cases  has  for  its  object  a  euthanasia. 
The  patient  is  made  much  less  offensive  to  herself  and  to  others  by 
deodorant  douches,  and  the  free  use  of  morphia  in  increasing 
doses  dulls  the  pain.  The  radical  treatment  involves  the  com- 
plete extirpation  of  the  growth  by  the  excision  of  its  base  and  of 
considerable  healthy  tissue  beneath  and  around  it.  The  thermo- 
cautery knife  should  be  extensively  employed  to  prevent  implan- 
tation metastasis  and  to  destroy  outlying  nests  of  carcinoma- 
tous cells.  The  complete  extirpation  of  the  vagina  has  been 
proposed  for  malignant  disease  and  tuberculosis  of  its  walls.  In 
the  hands  of  some  German  surgeons  the  operation  has  proved 
successful  and  not  especially  difficult.  A  circular  incision  is  made 
around  the  base  of  the  hymen  and  the  vagina  is  stripped  loose 
from  its  attachments  by  a  blunt  and  almost  bloodless  dissection 
to  the  uterus,  which  must  be  removed  by  a  vaginal  hysterectomy. 
The  site  of  the  vagina  is  obliterated  by  the  agglutination  of  raw 
and  granulated  surfaces.  It  was  found  necessary  in  a  few  cases 
to  incise  the  perineum  to  and  around  the  anus  in  order  to  obtain 
room  for  the  e.xcision  of  extensively  infiltrated  vaginal  walls  and 
for  the  vaginal  hysterectomy.  The  control  of  the  hemorrhage 
from  the  hemorrhoidal  vessels  proved  very  difficult. 

Pointed  Condylomata  of  the  vagina  are  rare.  Single  spurs 
springing  from  the  vaginal  mucous  membrane  associated  with 
masses  of  venereal  warts  on  the  vulva  are  common,  but  the  author 
has  only  seen  a  single  case  in  which  there  was  a  large  mass  of 
venereal  warts  growing  from  the  vaginal  vaults  and  the  cervix. 
The  appearance  is  quite  distinctive  and  differs  from  that  of  a 
cauliflower  epithelioma  enough  to  make  a  differential  diagnosis 
on  sight  possible.  The  color  is  a  light  pink,  contrasting  with  the 
deep  red,  ulcerated  appearance  of  an  epithelioma.  There  is  no 
ulceration  of  the-  condylomata.  The  epithelium  covering  the 
papillomatous  growth  is  normal.  The  mucous  membrane  around 
the  pedicles  is  normal.  There  is  no  infiltration.  The  micro- 
scopical examination  makes  the  differential  diagnosis  conclusive. 


Pointed   Condylomata  of  the  Vagina  191 


Fig.  207. — Masses  of  pointed  condylomata  removed  from  the  vaginal  vaults  and  the 

cervix. 


Fig.  208. — Venereal  wart  from  cervix  :   e,  Hypertrophied  squamous  epithelium;  c.t^ 
connective  tissue  (McConnell  and  J.  C.  Hirst). 


192  Diseases  and   Injuries  of  the  Vagina 

The  treatment  of  condylomata  in  the  vagina  is  their  excision. 
It  is  necessary  to  transfix  the  healthy  mucous  membrane  around 
their  bases  with  a  needle  and  catgut  and  to  tie  the  pedicle  made 
b}-  pulling  upon  the  growth.  Without  this  precaution  there  is 
profuse  hemorrhage. 

Foreign  Bodies  in  the  Vagina. — A  long  and  varied  catalogue 
of  foreign  bodies  found  in  the  vagina  could  be  prepared  from  the 
reported  cases.  ^  Needles,  hairpins,  spools,  spoons,  pine  cones, 
pipe  bowls,  and  pieces  of  wood  are  a  few  examples.  In  an  insane 
patient  in  the  Philadelphia  Hospital  a  medicine  cup  was  found  in 
the  vagina.  In  a  dispensary  patient  of  the  Howard  Hospital  a  piece 
of  glass  was  found  embedded  in  the  vaginal  wall  under  the 
mucous  membrane.  It  had  been  there  for  several  years,  since  a 
vaginal  douche  administered  in  Italy  during  which  the  glass 
nozzle  of  the  syi'inge  was  broken.  The  commonest  foreign 
body  in  the  vagina  is  a  neglected  pessary.  The  author  was 
asked  to  see  an  old  lady  sixty  }'ears  of  age  with  a  foul-smelling 
bloody  discharge,  naturally  suggesting  cancer.  A  pessary  was 
found  in  the  vagina,  much  to  the  patient's  surprise.  She  could  not 
remember  when  it  had  been  inserted,  but  was  certain  it  was  more 
than  twenty  years  before.  The  removal  of  the  pessary  and  a  daily 
douche  for  a  week  or  two  cured  the  vaginal  ulceration. 

The  most  dangerous  form  of  pessary  to  leave  in  the  vagina  a 
longtime  without  removal  is  the  ring  pessary  of  some  hard  mate- 
rial, such  as  hard  rubber.  It  is  very  likely  to  ulcerate  into  the 
bladder  and  to  embed  itself  deeply  in  the  vaginal  vault.  In  a 
patient  in  the  Philadelphia  Hospital  there  was  an  opening  in  the 
bladder  into  which  three  fingers  could  be  placed  and  the  ring 
pessary  of  hard  rubber  was  so  deeply  embedded  and  overgrown 
by  exuberant  granulation  tissue  that  it  could  only  be  removed 
by  clipping  off  with  bone  forceps  the  segment  exposed  in  the 
vesicovaginal  fistula.  Pulling  on  a  free  end  after  removing  about 
an  inch,  and  thus  rotating  the  pessary,  another  segment  was  ex- 
posed and  cut  off,  and  thus  the  whole  instrument  was  eventually 
removed  in  three  or  four  fragments. 

After  the  removal  of  the  foreign  body  it  may  be  necessary  to 
treat  extensive  ulceration,  fistulse  into  the  bladder  and  rectum, 
and  general  sepsis.  Fatal  results  are  recorded  from  peritonitis, 
general  sepsis,  and  obstruction  of  the  bowel. 

Fecal  Fistulse  in  the  Vagina. — The  commonest  fecal  fistula 
in  the  vagina  is  a  rectovaginal  fistula  the  result  of  an  imperfectly 
healed  complete  tear  of  the  perineum.  Occasionally  the  recto- 
vaginal septum  is  perforated  in  labor  without  injury  to  the  per- 
ineum. A  fetal  extremity  has  prolapsed  through  the  anus  before 
^Neugebauer,  "Archiv  f.  Gyn.,"  Bd.  xliii. 


Fecal  FistLilae  in  the  Vagina  193 

the  birth  of  the  child.  Ulcerative  processes  and  infection  in  the 
puerperiuni  with  suppuration  of  the  rectovaginal  septum  have 
resulted  in  the  formation  of  a  rectovaginal  fistula.  The  same 
result  has  followed  the  ulceration  associated  with  adynamic  and 
infectious  fevers. 

Other  causes  of  a  fecal  fistula  in  the  vagina  are  perforation 
of  the  posterior  vaginal  wall  and  the  bowel  by  instruments  used 
in  labor  or  to  induce  abortion  ;  falls  upon  some  object,  like  a  broom 
handle  or  the  small  bough  of  a  tree,  which  enters  the  vagina ; 
abscesses  in  the  tube  or  in  Douglas's  pouch  which  open  into 
the  vagina  and  into  the  bowel ;  prolapse  of  a  coil  of  intestine 
through  a  laceration  of  the  vaginal  vault  in  labor,  its  incarcera- 
tion, and  gangrene  ;  tight  packing  of  the  pelvis  with  gauze,  or  the 
use  of  a  drainage-tube  after  an  operation  for  pelvic  inflammation 
and  suppuration,  which  causes  ulceration  of  a  bowel-wall  already 
diseased  ;  and  wounds  of  the  bowel  in  vaginal  operations  for 
hysterectomy,  the  removal  of  the  uterine  appendages,  and  the 
evacuation  of  pelvic  abscesses.  The  ulceration  of  a  rodent 
ulcer,  tertiary  syphilis,  tuberculosis  and  cancer,  and  that  caused 
by  the  prolonged  retention  of  a  foreign  body,  is  a  cause  of  fecal 
fistula  in  the  vagina. 

The  symptom  of  a  fecal  fistula  in  the  vagina  is  the  involun- 
tary escape  of  gas  and  feces  from  the  vulva.  On  inspection  a 
small  projection  of  granulation  tissue  is  observed  a  short  distance 
within  the  vaginal  entrance,  usually  to  one  side  of  the  median 
line,  often  edematous  and  covered  with  a  purulent  discharge. 
Bubbles  of  gas  may  form  over  the  vaginal  orifice  of  the  fistula 
during  the  examination.  There  is  usually  a  brawny  infiltration 
along  the  fistulous  tract.  By  passing  a  surgeon's  probe  into  the 
fistula  from  the  vagina  and  inserting  a  forefinger  into  the  rectum 
the  communication  between  the  two  canals  is  readily  demonstrated. 
If  the  fistula  is  a  large  one,  it  may  be  possible  to  see  the  rectal 
mucous  membrane  through  it,  and  to  observe  fecal  masses  of  con- 
siderable size  passing  into  the  vagina.  The  finger  inserted  into 
the  rectum  may  be  passed  into  the  vagina  or  may  be  seen  in  the 
rectum  from  the  vagina. 

If  the  fecal  fistula  has  another  origin  than  an  imperfectly 
healed  perineal  laceration  in  labor,  it  may  be  situated  in  the 
vaginal  vaults,  almost  always  in  the  posterior,  although  two 
cases  are  recorded  in  the  anterior  vault.  It  is  important  to  de- 
termine whether  the  communication  is  between  the  vagina  and 
rectum  or  between  the  vagina  and  the  small  intestine.  This  is 
done  by  probing  the  fistula  and  inserting  a  forefinger  in  the 
rectum  as  high  as  possible,  by  the  use  of  the  proctoscope,  which 
enables  one  to  see  the  point  of  the  probe  emerging  into  the 
13 


194  Diseases  and   Injuries  of  the  Vagina 

bowel  anywhere  below  the  sigmoid  flexure,  or  by  noting  the 
character  of  the  feces  discharged.  It  is  also  important  to  note 
whether  all  the  feces  pass  from  the  fistula  (anus  praeternaturalis 
vaginalis)  or  whether  a  part  is  discharged  by  the  anus. 

The  treatment  of  a  fecal  fistula  in  the  vagina  differs  with  its 
situation  and  cause.  A  persistent  rectovaginal  fistula,  the  result 
of  an  imperfectly  healed  or  badly  repaired  perineal  tear,  is  easily 
cured.  A  grooved  director  is  passed  from  the  vagina  into  the 
bowel  and  out  through  the  anus  ;  the  perineum  is  divided  with  a 
knife  or  scissors,  the  fistulous  tract  is  scraped  with  a  sharp  curet, 
or  denuded  with  scissors  of  all  granulation  tissue,  and  the  wound 
is  united  as  in  the  secondary  operation  for  a  sphincter  tear  which 
has  been  unsuccessfully  repaired  (p.  175). 

A  fistula  in  the  vault  of  the  vagina  is  more  difficult  to  deal 
with.  Time  should  be  allowed  for  its  spontaneous  closure,  which 
occurs  quite  often.  Meanwhile  frequent  douching  of  the  vagina 
is  required.  If  a  persistent  fistula  communicates  with  the  rec- 
tum, the  fistulous  tract  may  be  dissected  out  and  the  hole  in  the 
bowel  sutured  after  its  edges  are  freshened.  The  vaginal  wound 
is  partly  closed  by  sutures  and  is  drained  by  a  narrow  strip  of 
gauze.  Even  if  the  sutures  in  the  bowel  give  way  the  fistula 
will  probably  be  diminished  in  size,  may  close  spontaneously,  or 
at  any  rate  is  more  easil}^  obliterated  by  a  second  operation  than 
b\'  the  first.  If  the  plastic  operations  prove  a  failure,  the  pro- 
posal of  P.  Segond  may  be  adopted.  A  transverse  incision  is 
made  in  the  posterior  vaginal  wall  above  the  sphincter  ;  the  rectum 
is  cut  across  and  exsected  up  to  the  fistula.  The  rectum  above 
this  point  is  brought  down  and  sutured  to  the  remnant  of  the 
bowel  just  above  the  sphincter.  Segond  secured  a  successful  re-- 
sult  by  this  method.^  If  the  fistula  communicates  with  the  small 
bowel,  a  plastic  operation  as  described  for  a  rectal  fistula  may  be 
attempted.  If  it  fail,  a  resection  and  anastomosis  of  the  gut 
may  be  tried  by  the  vaginal  or  abdominal  route,  but  the  opera- 
tion presents  formidable  difficulties  on  account  of  the  extensive 
adhesions  and  distorted  relations  of  the  intestinal  coils.  If  the 
fistula  is  large  and  there  is  a  vaginal  anus  by  which  all  the  feces 
escape,  an  attempt  at  closure  may  result  in  obstruction.  Before 
resorting  to  operation  plenty  of  time  should  be  allowed  for  a 
spontaneous  closure,  which  is  not  unlikely  to  occur. 

The  fecal  fistulae  in  the  vagina,  the  result  of  rodent  ulcer, 
tertiary  syphilis,  tuberculosis,  and  cancer,  are  usually  incurable. 
An  attempt  to  close  them  by  an  operation  leaves  a  larger  opening 
than  before. 

Vaginismus. — By  vaginismus  is  meant  a  spasmodic  contrac- 

^  "  Ann.  de  Gyn.  et  d'Obstet.,"  vol.  xliv,  p.    i. 


Vagin 


ismus  195 


tion  of  the  bulbocaveniosus  and  of  the  levator  ani  muscles,  pre- 
venting coitus  or  making  impossible  the  insertion  of  the  tip  of  the 
forefinger  in  an  attempted  examination.  The  condition  is  usually 
not  detected  until  after  marriage,  when  coitus  is  found  to  be 
impossible.  A  feeling  of  delicacy  prevents  the  woman  from 
seeking  medical  advice,  so  that  as  a  rule  months  or  years  elapse 
after  the  first  futile  attempt  at  intercourse  before  the  physician  has 
an  opportunity  to  examine  the  patient.  ^ 

In  the  examination  of  some  cases  no  evidence  of  spasm  in  the 
constrictor  muscles  of  the  vagina  appears.  One  or  two  fingers 
are  easily  inserted  in  the  vagina,  and  a  bivalve  speculum  may  be 
opened  its  full  width.  It  is  only  the  nervous  excitation  of  the 
attempted  intercourse  that  excites  the  spasm.  In  other  cases  it 
is  impossible  to  touch  the  external  genitalia  without  producing  the 
most  violent  contraction,  the  most  marked  evidences  of  acute  pain 
and  nervous  excitement.  The  buttocks  are  lifted  off  the  examin- 
ing table,  the  thighs  are  forcibly  approximated,  and  the  patient  re- 
sists the  attempted  examination  violently.  If  an  examination  is 
made  in  the  first  few  months  after  marriage,  the  results  of  futile 
attempts  at  intercourse  are  seen  in  abrasions  of  the  inner  surfaces 
of  the  labia  and  on  the  free  edges  of  the  hymen,  the  latter  being 
the  seat  often  of  exuberant  granulations  that  bleed  easily  on  the 
least  touch.  Ordinarily  there  is  no  disease  of  the  genitalia  ;  the 
affection  is  a  distinct  neurosis.  It  is  therefore  most  commonly 
seen  in  neurasthenic  and  hysterical  subjects.  But  any  of  the 
painful  or  irritating  affections  of  the  vulva  may  have  vaginismus 
as  a  secondary  result,  such  as  vulvitis,  kraurosis  and  pruritus 
vulvae,  or  urethral  caruncle.  An  inflammatory  disease  of  the  uterine 
appendages  may  make  coitus  so  painful  that  a  dread  of  it  excites 
a  spasm  of  the  muscles.  Vaginismus,  therefore,  may  develop  in 
women  who  have  been  married  for  years  and  have  borne 
children. 

Before  attempting  to  treat  vaginismus,  a  careful  examination 
of  the  genitalia  must  be  made  ;  if  necessary,  under  anesthesia. 
If  it  depends  upon  some  source  of  local  irritation,  its  cure  is 
hopeless  unless  the  cause  is  removed.  Vulvitis,  pruritus,  krau- 
rosis, a  caruncle,  each  demands  its  appropriate  treatment.  In- 
flammatoiy  diseases  of  the  uterine  appendages  may  require  sur- 
gical intervention  or  local  applications.  Ordinarily,  however,  no 
local  cause  is  discoverable,  and  the  treatment  is  directed  toward 
overcoming  the  spasmodic  contraction  of  the  muscles  around  the 
vulvar  and  vaginal  orifices.  If  there  are  painful  abrasions  the 
result  of  unsuccessful  attempts  at  intercourse,  the  treatment  of 

^  In  one  of  the  author's  patients  the  condition  had  persisted  eighteen  months  ;  ia 
another,  eight  years  ;  and  in  another,  twelve  years. 


196 


Diseases  and  Injuries  of  the  Vagina 


the  vaginismus  must  be  postponed  until  they  are  healed,  for  if 
the  physician  inflicts  pain  upon  the  patient  she  rarely  has  the 
resolution  to  persist  in  an  effort  to  be  cured.  The  first  requisite 
for  success  is  to  impress  the  patient  with  the  belief  that  a  bougie 
can  be  inserted  in  the  vagina  without  pain.  A  pledget  of  cotton 
soaked  in  a  4  per  cent,  solution  of  cocain  is  gently  placed  in  the 


Fig.  209. — Y'Shaped  incision  through  the  levator  ani  muscles  and  the  perineum  for 

vaginismus. 


Fig.  210. — Insertion  of  the  sutures  in  the  operation  for  vaginismus. 

vulvar  orifice  and  allowed  to  remain  five  minutes.  Then  a 
Hegar's  bougie  of  small  size,  no  larger  than  one's  forefinger, 
warmed  and  well  oiled,  is  cautiously  and  slowly  passed  into  the 
vagina.  Nothing  more  should  be  attempted  on  the  first  visit. 
Two  days  later,  with  the  same  precautions,  a  larger  instrument 
is  passed,  and  so  on  until  the  patient's  confidence  is  gained  and 


Vaginismus  197 

she  is  convinced  that  the  insertion  of  the  instrument  is  not  diffi- 
cult. She  is  then  provided  with  a  set  of  graduated  bougies  up  to 
an  inch  and  a  half  in  diameter,  ^  with  instructions  to  use  them 
herself  daily,  progressing  as  fast  as  possible  in  the  use  of  larger 
sizes  without  inflicting  pain  upon  herself,  and  allowing  the  instru- 
ment to  remain  in  the  vagina  for  an  hour  at  a  time  while  she 
rests  in  bed.  The  author  keeps  a  set  of  these  bougies  to  lend 
to  patients  with  vaginismus.  It  is  a  frequent  experience  to  have 
them  returned  triumphantly  in  about  six  weeks  with  the  state- 
ment that  they  are  no  longer  needed. 

If  the  case  is  of  long  duration  or  is  very  aggravated  in 
degree,  nothing  as  a  rule  is  to  be  hoped  from  gradual  dilatation. 
It  is  necessary  to  split  the  perineum  half-way  to  the  anus  and  to 
make  two  deep  incisions  in  the  vaginal  sulci,  an  inch  or  more  in 
depth  and  extending  more  than  an  inch  up  the  vaginal  walls, 
imitating  the  sulci  tears  of  a  labor.  A  transverse  row  of  sutures 
is  then  inserted  from  above  downward,  uniting  the  vaginal  mucous 
membrane  to  the  skin  of  the  perineum.  The  result  is  a  gaping 
vulvar  orifice  and  vaginal  introitus,  and  an  abrogation  of  the  con- 
tractile power  of  the  bulbocavernosus  and  to  a  lesser  degree  of 
the  levator  ani  muscle.  The  author  has  uniformly  cured  in  this 
way  the  worst  cases  of  vaginismus. 

The  statement  is  copied  from  one  book  to  another  that  a 
spasmodic  contraction  of  the  levator  ani  in  coitus  is  responsible 
for  that  awkward  accident,  penis  captnnis,  but  no  authentic  cases 
are  given,  and  the  author  confesses  to  a  skepticism  as  to  its  pos- 
sibility. 

1  Hegar's  glass  bougies  for  dilatation  of  the  cervix  in  pregnancy  and  labor  are 
reasonable  in  price  and  answer  the  purpose. 


PART  V. 
INJURIES  AND  DISEASES  OF  THE  CERVIX. 

The  cervix  uteri,  or  neck  of  the  uterus,  extends  from  the 
level  of  the  internal  to  the  external  os,  or  from  the  inferior 
border  of  the  lower  uterine  segment  to  the  external  os.  One- 
third  of  the  cervix,  the  vaginal  portion,  projects  like  a  nipple  into 
the  vaginal  vault.  The  vaginal  portion  of  the  cervix  is  divided 
into  anterior  and  posterior  lips  by  the  external  os,  which  is  usually 
a  transverse  slit  or  oval  opening.  The  posterior  lip  is  the  longer 
of  the  two. 

The  vaginal  portion  of  the  cervix,  or  all  that  portion  of  the 
cervix  below  the  attachment  of  the  vaginal  mucous  membrane,  is 


Corp.  mucosum.  Corp.  mucosum. 

Fig.  211.  Fig.  212.  Fig.  213. 

Figs.  211,  212. — External  os  uteri  of  nullipara.  Fig.  213. — External  os  uteri 

of  a  multipara. 

conical  in  shape,  resting  with  the  external  os  against  the  posterior 
wall  of  the  vagina,  which  is  thickened  at  this  point  (cervical 
pillow).  The  anterior  lip  is  supported  by  the  posterior  wall  of 
the  vagina,  and  the  posterior  lip  is  in  immediate  contact  with  the 
mucous  membrane  of  the  posterior  vaginal  vault. 

The  external  os  in  a  nulUparous  woman  is  sometimes  cir- 
cular, but  more  frequently  elliptical,  with  the  long  diameter 
of  the  opening  transversely.  Projecting  from  the  external  os 
there  is  usually  a  plug  of  thick,  tenacious,  clear  mucus,  the 
mucous  plug  of  the  cervix.  All  that  part  of  the  cervix  above 
the  mucous  membrane  of  the  vagina,  to  the  isthmus  uteri,  the 
lower  uterine  segment,  or  the  level  of  the  internal  os,  is  called 
the  supravaginal  portion   of  the  cervix.      It  is  longer  anteriorly 


Anatomy  of  the  Cervix 


199 


than  posteriorly,  and  is  firmly  connected  with  the  vaginal  wall  by 
muscular,  elastic,  and  connective  tissue.  Above  the  attachment 
of  tiie  vagina  anteriorly  the  cervix  is  in  part  attached  to  tlie 
bladder  and  in  part  is  covered  by  the  peritoneum  lining  the 
vesico-uterine  pouch,  which  is  rather  loosely  bound  to  it  by  con- 
nectixe  and  elastic  .tissue.  Posteriorly  the  cervix  above  the 
vaginal  wall  is  covered  b\'  peritoneum,  firmly  attached  to  it. 

In  a  longitudinal  section  the  cervix  is  di\'ided  into  two  parts 
— the  muscular  portion,  or  body,  and  the  canal.  The  former  has 
the  same  unstriped  muscular  fibers  as  the  corpus  uteri,  but  the 
individual  fibers  are  smaller,  less  compactly  arranged,  and  there 
is  an  abundance  of  connective  tissue.      There  are  three  layers  of 


Fig.  214. — Transverse  section  of  the  cervix  uteri :  a,  Cervical  muscularis  ;  h, 
right  ureter  ;  c,  d,  uterovaginal  venous  plexus  ;  i\  vesicovaginal  plexus  ;  f,  orifice  of 
right  ureter  ;  g,  internal  urethral  orifice  ;  h,  bladder-wall  ;  i,  left  ureter ;  J,  paramet- 
rium ;  k,  serous  coat ;  /,  mucous  coat  ;   w,  cervical  glands  (Waldeyer). 


muscle-fibers  in  the  cervix — an  outer  and  an  inner  longitudinal 
layer  and  a  median  circular  layer.  The  latter  is  much  the 
thickest  and  strongest.  The  cervical  canal  is  spindle-shaped, 
contracted  above  and  below  at  the  internal  and  external  os.  The 
former  is  the  narrowest  portion  of  the  uterine  cavity,  the  con- 
traction extending  a  length  of  4  to  5  millimeters.  The  broadest 
part  of  the  cervical  canal  is  its  middle. 

The  mucous  membrane  of  the  cervical  canal  is  sharply  differ- 
entiated from  that  of  the  vaginal  portion  below  and  that  of  the 
uterine  cavity  above.  It  is  pale  gra}ish-red,  soft,  and  from  i  to 
2  millimeters  thick.    There  is  no  submucosa.    The  mucous  mem- 


>oo 


Injuries  and  Diseases  of  the  Cervix 


brane  rests  directly  upon  the  muscle.      The  dividing  line  between 
the  cylindrical  epithelium  of  the  canal  and  the  squamous  epithe- 


Fig.  215. — Normal  endometrium  of  cervix  :  s,  Stroma  ;  s.e,  surface  columnar  epithe- 
lium ;  g,  glands  (McConnell  and  J.  C.  Hirst). 


Fig.  216. — Longitudinal   section  of  cervix  of  a  nulliparous  woman,  showing  palmre 

plicatae. 


liuni  of  the  vaginal  portion  is  normally  the  external  os,  but  the 
former  may  extend  far  out  upon  the  vaginal  portion  (erosion)  and 


Injuries  of  the  Cervix  201 

the  latter  may  extend  high  into  the  cervical   canal,  even  into  the 
uterine  cavity. 

The  ciliated  epithelial  cells  are  long  and  slender.  The  nuclei 
are  long  and  lie  mainly  toward  the  bases  of  the  cells.  The 
mucous  membrane  is  thicker  than  that  of  the  uterine  cavity,  more 
sharply  divided  from  the  musculature  under  it,  possessing  more 
connective  tissue  and  fewer  round-cells.  On  the  anterior  and 
posterior  walls  of  the  canal  the  mucous  membrane  is  thrown  into 
transverse  folds  i^palmce  plicatcE  or  arbor  vitcB),  making  a  figure 
like  the  ribs  of  a  leaf.  The  glands  of  the  cervical  mucous  mem- 
brane are  tubular,  with  many  lateral  processes  and  projections. 
They  open  in  the  creases  of  the  palmar  phcatae,   secreting  the 


Fig.  217. — Longitudinal  section  of  cervix  of  a  multipara,  showing  obliteration  of  the 

palmas  plicatse. 

thick,  tenacious  mucus  which  normally  fills  the  cervical  canal 
and  may  project  from  the  external  os. 

The  cilia  of  the  cervical  epithelium  lash  toward  the  external 
OS,  and  those  of  the  glands  from  their  bases  toward  their  orifices. 

Injuries  of  the  cervix  are  possible  as  the  result  of  attempts 
to  induce  abortion,  from  the  use  of  instruments  to  dilate  the 
cervical  canal,  in  consequence  of  the  extraction  of  a  tumor  from 
the  uterine  cavity  ;  but  the  injuries  of  labor  are  overwhelmingly 
more  numerous  than  any  others.  They  may  take  one  of  three 
forms  :  longitudinal  lacerations,  circular  lacerations,  and  abrasions. 

Longitudinal  lacerations  are  usually  bilateral,  more  or  less 
completely  dividing  the  anterior  and  posterior  lips.  From  the 
weight  of  the  uterus  and  the  drag  of  the  vaginal  walls  at  their 
attachments  anteriorly  and  posteriorly,  the  two  lips  of  the  cervix 


202 


Injuries  and  Diseases  of  the  Cervix 


are  pushed  and  pulled  apart  until  eventually  they  diverge  from 
one  another  like  the  ends  of  a  split  stalk  of  celery.  This  con- 
dition is  called  ectropio}i  or  eversion. 

Frequently  the  anterior  lip  is  more  everted  than  the  posterior 


Fig.    218. — Incomplete  laceration    and 
crescentic  shape  of  os. 


Fig.  219. — Bilateral  laceration  and 
eversion. 


Fig.  220. — Bilateral  laceration  and 
unequal  eversion  of  lips. 


Fig.  221.  —  Bilateral  laceration  and  erosion. 


because  of  the  direction  of  the  uterine  axis  from  before  backward 
and  from  above  downward,  which  imposes  the  greatest  weight  on 
the  anterior  lip,  and  because  of  the  lower  attachment  of  the 
vaginal  wall  to  this  lip,  which  pulls  it  forward.  The  result  of 
this  asymmetrical  eversion  of  the  lips  is  to  give  a  crescentic  form 


PLATE  G. 


Injuries  and  erosion  of  the  cervix  :    i-i  ■,  Types  of  erosion  and  cicatricial  infiltration 
of  the  cervix  ;    15,  conical  cervix  and  pinhole  os. 


Injuries  of  the   Cervix 


203 


to  the  OS  uteri,  with  the   concavity  directed  forward,  and  to  give 
to  the  cervix  and  os  the  shape  of  a  shark's  mouth. 

The  eversion  of  the  Hps  exposes  the  deep  red  mucous  mem- 
brane of  the  cervical  canal,  which,  undergoing  hyperplasia  from 
irritation,  may  encroach  upon  the  light  pink  squamous  epithelium 
of  the  vaginal  portion  of  the  cervix,  giving  to  the  latter  a   raw, 


Fig.  222. — Bilateral  laceration  and  eversion. 


Fig.   223. 


-Incomplete  bilateral   lacer- 
ation. 


Fig.  224. — Stellate  laceration. 


inflamed,  angry  appearance.  This  condition  is  called  erosion  of 
the  cervix  (page  214). 

If  the  tear  of  the  cervix  is  unilateral,  the  sound  side  acts  as 
a  splint  and  prevents  ectropion  and  erosion. 

The  laceration  may  divide  the  cervix  anteriorly  or  posteriorly 
as  well  as  laterally,  thus  having  three  or  more  arms.  Such  a 
tear  is  called  stellate. 


204  Injuries  and  Diseases  of  the  Cervix 

The  lateral  lacerations  may  extend  into  the  vaginal  vaults 
dividing  the  vaginal  and  the  supravaginal  portions  of  the  cervix. 
Such  an  injury  is  complicated  by  cicatrices  fixing  the  cervix 
to  the  vaginal  vaults,  or  by  fibrous  bands  joining  the  cervix  to 
the  vault  of  the  vagina.  All  extensive  injuries  of  the  cervix- 
are  likely  to  be  followed  by  cicatricial  infiltration  which  more  or 
less  completely  displaces  the  normal  myometrium,  replacing  the 
elastic  cervical  muscle  by  scar-tissue  as  dense  and  hard  as  carti- 
lage. The  mucous  membrane  of  the  canal  is  altered  in  time, 
the  columnar  epithelium  being  replaced  by  squamous  epithelium, 
the  palmje  plicatae  being  obliterated  and  the  mouths  of  the  cervi- 
cal glands  obstructed  so  that  the  cervix  is  studded  with  little 
retention  cysts  that  appear  on  the  surface  of  the  vaginal  portion 
as  small  vesicles  discharging,  when  pricked,  the  characteristic 
clear  viscid  mucus  of  the  cervix  (glands  or  ovules  of  Naboth).^ 


Fig.  225. — Multiple  incomplete  lacerations. 

In  consequence  of  the  irritation  of  the  cervix  from  cicatricial 
infiltration,  the  obstruction  of  the  glands,  and  possibly  its  fixa- 
tion by  adhesions,  there  is  a  hyperplasia  of  all  the  constituent 
parts, — muscle,  connective  tissue,  and  glands, — causing  a  hyper- 
trophy of  the  vaginal  portion,  which  becomes  heavy  and  large, 
filling  the  vaginal  vault  and  dragging  upon  the  uterus.  In  other 
cases  there  is  a  partial  necrosis  of  the  vaginal  portion,  diminish- 
ing its  projection  into  the  vagina  and  reducing  it  to  a  mass  of 
fibrous  tissue,  covered  with  squamous  epithelium  and  seamed 
with  the  fissures  of  two  or  more  longitudinal  tears. 

Tlie  result  of  a  bilateral  or  stellate  tear,  or  of  extensive 
cicatricial  infiltration,  is  a  never-ending  local  irritation  leading 
to  chronic  congestion  not  only  of  the  cervix,  but  of  the  whole 
uterus ;  to  endocervicitis  and  to  endometritis  ;  to  cervical  catarrh 
and  a  consequent  leukorrhea.      There  is  always  danger  of  epithe- 

'  It  was  believed  in  the  prescientific  era  that  these  cysts  were  ova. 


PLATE  7. 


^-iii_r--l^ 


Injuries  and  erosion  of  the  cervix  :    i.  Normal  cervix  ;   2,  3,  4,  7)  9>  ii-  12,  erosion 
of  the  cervix  ;   5,  6,  8,  10,  endocervicitis  and  follicular  cervicitis. 


Injuries  of  the  Cervix 


205 


lioma  from  the  constant  and  long-continued  irritation  ;  the 
vast  majority  of  these  growths  have  their  origin  in  an  old  in- 
jury of  the  cervix.  As  a  prophylactic  measure  alone,  therefore, 
the  repair  of  lacerations  of  the  cervix  is  indicated.  Moreover,  the 
leukorrhea  and  the  nienorrhagia  of  endocervicitis  and  endome- 
tritis may  only  be  permanently  cured  by  the  repair  of  cervical 
injuries.  It  is  possible,  also,  to  witness  a  varied  train  of  neuras- 
thenic and  reflex  symptoms  referable  to  lacerations  of  the  cervix 


Fig.  226. — Fibromucous  band  uniting  cervix  with  vaginal  vault. 


and  only  disappearing  after  their  repair  ;  but  the  influence  of 
cervical  injuries  upon  the  general  health  has  been  much  exag- 
gerated in  the  past,  and  the  physician  must  be  on  his  guard 
against  attributing  too  much  importance  to  the  local  lesion  in  a 
neurasthenic  individual  with  impairment  of  the  general  health. 

A  circular  laceration  of  the  cervix  results  in  the  detachment 
of  the  vaginal  portion.  There  is  no  likelihood  of  trouble  subse- 
quently, for  the  ultimate  result  is  as  good  as  is  secured  by  a  de- 
liberate amputation. 


2o6  Injuries  and  Diseases  of  the  Cervix 

Abrasions  of  the  cervix  are  of  no  moment  unless  they  are 
apposed  to  abraded  surfaces  on  the  vaginal  vaults,  in  which  case 
the  cervix  may  adhere  to  the  vaginal  wall  immediately  or  by  a 
band  of  cicatricial  and  mucous  tissue. 

The  Treatment  of  a  Lacerated  Cervix. — The  immediate  repair 
of  lacerations  of  the  cervix  is  possible,  but  not  always  advisable, 
for  several  reasons  :  The  stitches  which  are  tight  enough  when 
inserted  hang  loose  in  a  day  or  two  on  account  of  the  reduction 
in  the  size  of  the  cervix  by  involution ;  the  bruised  and  edematous 
condition  of  the  cervix  and  the  profuse  flow  of  lochia  over  it  do 
not  conduce  to  primary  union  of  the  wounds  ;  the  exposure  of 
the  OS  uteri  as  the  cervix  is  pulled  into  view  with  bullet  forceps 
predisposes  to  infection  of  the  uterine  cavity,  and  many  a  case 
of  lacerated  cervix  heals  spontaneously  if  the  woman  is  kept  quiet 
after  labor  and  vaginal  douching  is  avoided.  Intermediate  re- 
pairs of  the  cer\ix  in  the  early  puerperium  after  forty-eight  hours 
are  always  practicable  and  sliould  be  the  practice  of  the  specialist 
at  least.  After  the  completion  of  the  puerperium,  if  there  is 
much  erosion,  applications  of  nitrate  of  silver  solution  (gr.  xx 
to  5j)  to  the  cervix  every  other  day  soon  reduce  the  hyperplasia 
of  the  columnar  epithelium  and  restore  a  healthy  appearance.  If 
there  is  considerable  eversion  with  the  likelihood  of  continued 
irritation,  repair  of  the  injury  should  be  recommended.  If  the 
patient  is  first  seen  long  after  the  labor  in  which  she  was  injured, 
the  decision  in  regard  to  operation  is  governed  by  a  number  of 
considerations.  A  unilateral  tear  as  a  rule  needs  no  treatment, 
unless  there  is  extensive  cicatrization.  A  stellate  tear  without 
erosion  or  ectropion  does  not  necessarily  demand  operation.  A 
bilateral  tear  with  ectropion,  but  with  no  erosion,  without  evi- 
dences of  extensive  cicatrization,  and  with  no  associated  leukorrhea 
or  metrorrhagia,  is  not  of  itself  an  indication  for  operation.  On 
the  contrary,  if  there  is  erosion  and  ectropion,  with  leukorrhea 
and  menorrhagia ;  if  there  is  considerable  hypertrophy,  cicatricial 
infiltration,  or  fixation  of  the  cervi.x,  an  operation  is  advisable. 

Preparatory  treatment  is  often  of  advantage  before  the  opera- 
tion. An  application  of  nitrate  of  silver  solution,  pricking  the 
retention  cysts,  and  applying  a  tampon  saturated  with  boro- 
glycerid  every  other  day  for  a  week  or  two,  produce  a  suprising 
improvement  in  the  appearance  of  the  cervix  and  insure  a 
greater  certainty  of  success  for  the  operative  treatment. 

The  operation  selected  for  a  cervical  injury  difters  with  the 
character  of  the  tear  and  the  condition  of  the  cervix.  A  simple 
bilateral  laceration  indicates  Emmet's  trachelorrhaphy.  A  stel- 
late tear,  great  hypertrophy,  extensive  cicatricial  infiltration,  and 
fixation  of  the  cervix  indicate  an  amputation.      Whenever  one  is 


The  Treatment  of  a  Lacerated   Cervix 


207 


in  doubt  as  to  the  suitable  form  of  operation,  it  is  better  to  decide 
on  an  amputation.  The  coaptabiHty  of  the  cervical  lips  is  tested 
by  bringing  them  together  with  tenacula.  A  careful  examination 
of  the  uterine  appendages  should  be  made  before  operating  on  the 
cervix,  for  pelvic  inflammation  contraindicates  such  an  operation, 


Fig.  227. — Displaying  a  lacerated  cervix  by  pulling  it  out  of  the  vulva. 


unless  it  is  immediately  followed  by  an  abdominal  section  for  the 
removal  or  other  surgical  treatment  of  chronically  inflamed,  dis- 
tended, or  adherent  tubes  and  ovaries. 

As  in  all  plastic  operations  in  the  pelvis,  but  most  particu- 
larly in  those  upon  the  cervix,  a  curettage  of  the  uterine  cavity 
should  precede  the  plastic  operation.      (See  page  645.) 


2o8 


Injuries  and   Diseases  of  the  Cervix 


Emmet's  operation  for  bilateral  laceration  of  the  cervix  is 
performed  by  catching  each  lip  of  the  cervix  with  a  bullet  forceps 
or  double  tenaculum,  which  pulls  the  cervix  into  view.  A  spec- 
ulum is  not  necessar}'.  An  assistant  holds  the  tenacula  apart, 
thus  separating  the  lips,  and  pulls  them  to  one  side,  exposing  the 
tear  first  to  be  repaired.  The  area  to  be  denuded  is  marked  by 
a  sharp  knife  cutting  rather  deeply,  care  being  taken  to  leave 
a  wide  enouo;h   cervical   canal.      The   mucous   membrane  within 


Fig.  228. — Showing  incisions  made  by  a  knife,  marking  out  area  to  be  denuded  ; 
"the  flaps  removed  in  one  piece  by  scissors  ;  lines  defining  area  of  denudation ;  and 
scissors  removing  tissue  in  one  piece. 


the  incisions  is  seized  with  a  rat-toothed  forceps  and  cut  out, 
with  some  underlying  tissue,  in  one  piece  by  small,  sharp-pointed 
scissors  curved  on  the  flat.  The  long-handled  curved  Emmet 
scissors  are  awkward  and  unnecessary.  The  other  side  is  simi- 
larly treated.  At  the  upper  angle  of  the  wound  the  points  of 
the  scissors  cut  quite  deeply  to  remove  the  cicatricial  plug,  on 
which  some  operators  lay  great  stress.  The  denudation  being 
completed,  interrupted  sutures  of  silkworm-gut  are  inserted  and 
gripped  with  a  hemostat.     After  all  the  sutures  are  in  place  they 


The  Treatment  of  a  Lacerated  Cervix 


209 


are  shotted  one  side  at  a  time  from  above  downward,  an  assistant 
sponging  the  wound  clean  of  blood  as  each  shot  is  run  home 
and  clamped.  The  sutures  are  cut  off  about  an  inch  from  the 
shot  for  convenience  of  removal. 

There  are  three  methods  of  amputating  the  cervix  to  be  con- 
sidered, the  selection  depending  upon  the  cervical  condition. 

In  the  Simon's  operation  the  cervix,  seized  by  the  two 
bullet  forceps,  one  in  each  lip,  is  split  laterally  on  both  sides  with 


Fig.  229. — I,  Denudation  for  repair  of  lacerated  cervix  ;   2,  sutures  inserted  ;   3, 

sutures  united. 


straight  scissors,  one  blade  in  the  cervical  canal,  the  other  upon 
the  exterior  of  the  vaginal  portion.  A  wedge-shaped  piece  is 
exsected  from  the  whole  width  of  each  lip  and  a  longitudinal 
piece  is  exsected  from  the  inner  edges  of  the  lateral  wounds  on 
both  sides.  Two  sutures  of  silkworm-gut  are  inserted  on  each 
side  as  in  Emmet's  trachelorrhaphy,  and  two  or  more  sutures 
are  placed  in  the  anterior  and  in  the  posterior  lips,  uniting  the 
triangular  wounds  left  by  the  wedge-shaped  exsections.  The 
junction  of  the  sutures  by  shot  makes  a  conical  cervix  reduced 
14 


2IO  Injuries  and   Diseases  of  the  Cervix 

in  length  and   breadth  compared  with  its  dimensions  before  the 
operation. 

In  the  Hegar  amputation  of  the  cervix  a  circular  incision  is 


Fig.  230. — Simon's  cone-shaped  excision  of  the  vaginal  portion  :  a,  Sutures  inserted  ; 

b,  sutures  tied. 


|t 

i 

m 

^ 

/ 

J 

i 

;* 

IP 

f  /< 

Fig.  231. — First  incision  for  Hegar's  amputation  of  the  cervix. 


made  at  the  junction  of  the  vaginal  vaults  and  the  vaginal  portion. 
A  cone-shaped  exsection  of  the  whole  cervix  is  next  made  by 
dissection  with  a  knife.  The  two  bullet  forceps  that  had  been 
used  to  pull  the  cervix  down  are  shifted  from  the  piece  removed 


The  Treatment  of  a  Lacerated   Cervix  211 

to  the  anterior  and  posterior  walls  of  the  supravaginal  portion  of 
the   cervix,  the  inner   hook    of  each   instrument  transfixing   the 


Fig.  232. — Cervix  removed  by  Hegar's  Fig.    233. — Hypertrophied,    elon- 

amputation.  gated  cervix  removed  by  Hegar's  am- 

putation. 


Fig.  234. — Hegar's  amputation  ;  stitches  introduced. 


mucous   membrane  of  the   cervical   canal.     The  sutures,  which 
may  be  of  catgut,  are  inserted  two  on  each  side  of  the  cervical 


212  Injuries  and   Diseases  of  the  Cervix 

canal,  without  emerging  in  it,  running  from  before  backward, 
bringing  together  the  mucous  membrane  of  the  vagina  over  the 
raw  surfaces  of  the  cervix  on  both  sides  of  the  canal,  and  two  or 
three  sutures  each  through  the  posterior  and  anterior  walls  of  the 
cervix,  uniting  the  vaginal  and  the  cervical  mucous  membranes. 
This  modification  of  the  original  Hegar  amputation,  in  which  all 
the  stitches  emerged  in  the  cervical  canal,  makes  a  much  neater 
coaptation  and  gives  a  more  satisfactory  ultimate  result. 

In  Schroeder's  operation  the  cervix  is  split  laterally.  The 
whole  cervical  mucous  membrane  is  excised  with  a  great  part  of 
the  myometrium  under  it.      The  squamous  mucous  membrane  of 


Fig.  235. — Hegar' s  amputation  ;   stitches  tied. 


the  vaginal  portion  is  preserved  and  is  turned  into  the  cervical 
canal,  where  it  is  sutured.  The  lateral  wounds  are  united  with 
interrupted  sutures.  ^ 

The  first  form  of  amputation  is  adapted  to  cases  of  hypertro- 
phy of  the  cervix,  more  particularly  in  its  breadth.  It  is  the  best 
operation  in  women  of  child-bearing  age.  The  second  method 
is  most  suitable  in  cases  of  complex  stellate  tear,  extensive  cica- 
tricial infiltration,  an    unhealthy   condition   of  the   cervical  canal 

'  Pouey's  operation  is  designed  to  accomplish  the  same  result  as  Schroeder's,  but 
is  not  so  satisfactory.  A  longitudinal  incision  is  made  through  the  whole  length  of 
the  mucosa  of  the  cervical  canal.  A  cuff  or  muff  of  mucosa  with  an  underlying  layer 
of  myometrium  is  dissected  out  of  the  cervical  canal ;  the  mucous  membrane  of  the 
external  os  is  joined  to  that  of  the  internal  os. 


The  Treatment  of  a  Lacerated  Cervix         213 


Fig.  236. — Schroeder's  single-flap  excision  of  the  vaginal  portion  :  A,  Excision 
made,  sutures  placed  on  anterior  lip  and  tied  on  posterior  ;  I  and  2,  lateral  sutures. 
B,  Longitudinal  section  through  cervix  ;  d  e,  transverse  incision  ;  fe,  longitudinal  in- 
cision joining  the  first  and  severing  the  mucous  membrane  and  part  of  the  muscular 
tissue  from  the  cervix  ;  b  c,  course  of  a  suture ;  g,  ovula  of  Naboth.  C,  Longitudinal 
section  after  the  sutures  are  tied. 


Fig.  237.  —  Superinvolution  or  atrophy  of  the  cervix. 


2  14  Injuries  and  Diseases  of  the  Cervix 

extending  a  considerable  distance  upward,  and  to  an  elongated 
cervix.  It  is  the  best  operation  in  women  at  or  past  the  meno- 
pause. Schroeder's  operation  is  intended  to  remove  diseased 
mucosa  from  the  cervical  canal. 

Atropliv  ci)id  siipcriiivoliition  of  the  cervix  are  associated  with 
the  same  conditions  in  the  uterus.  The  symptoms  are  referable 
to  the  latter.  The  only  justification  for  separate  mention  of  these 
conditions  of  the  cervix  is  their  diagnostic  value  in  the  recogni- 
tion of  atrophy  and  superinvolution  of  the  uterus  on  a  specular 
examination.  The  cervix  is  diminished  in  all  directions,  and 
presents  in  miniature  the  varying  conditions  seen  in  the  well- 
developed  or  normally  involuted  vaginal  portion.  That  is,  it 
may  be  conical  in  shape,  may  show  signs  of  the  various  injuries 
to  which  it  is  subject,  or  may  have  the  appearance  represented  in 
figure  237,  due  to  a  superinvolution  of  the  myometrium,  with  a 
lesser  degree  of  atrophy  of  the  cervical  endometrium,  causing  a 
prolapsus  and  protrusion  of  the  latter. 

Cervicitis. — The  squamous  epithelium  of  the  vaginal  portion 
may  be  the  seat  of  inflammations  which  have  the  same  causes, 
present  the  same  appearance,  and  require  the  same  treatment  as 
the  various  kinds  of  vaginitis.  There  is  a  peculiar  form  of  cervi- 
citis, however,  which  deserves  a  special  description. 

Erosion  of  the  Cervix. — In  consequence  of  an  irritation  of  the 
vaginal  portion  of  the  cervix  and  of  the  canal,  the  squamous  epi- 
thelium of  the  former  is  converted  into  columnar  epithelium  over 
varying  distances  from  the  external  os,  sometimes  almost  to  the 
vaginal  vaults.  ^  The  commonest  cause  of  irritation  is  a  lacera- 
tion of  the  cervix,  therefore  erosion  is  most  often  associated  with 
laceration  of  the  cervix.  Another  common  cause,  however,  is 
a  catarrh  of  the  cervix.  A  typical  erosion,  therefore,  may 
be  seen  in  nuUiparous  women,  giving  somewhat  the  appear- 
ance of  laceration  and  ectropion  if  the  erosion  extends  on  the 
anterior  and  posterior  lips  rather  than  laterally.  The  error  has 
been  made  in  such  cases,  of  describing  a  "  congenital  laceration 
of  the  cervix,"  which  is,  of  course,  impossible.  Histologically, 
Ruge  and  Veit  have  demonstrated  that  the  basic  cells  of  the 
squamous  epithelium  on  the  vaginal  portion  are  converted  into 
cylindrical  epithelium,  the  squamous  cells  above  them  disappear- 
ing. There  is  a  tendency  to  tubular  gland-formation  by  an 
ingrowth  of  these  cells  into  the  myometrium.  Often  there 
is  an  exuberant  growth  outward,  especially  of  the  interglan- 
dular  connective  tissue.  As  one  of  these  two  tendencies  pre- 
dominates, there  is  a  follicular  or  a  papillary  erosion.      As  may 

1  Ruge  and  Veit,  "  Zur  Pathologie  der  Vaginalportion,"  "  Zeitschr.  f.  Geburtsh. 
u.  Gyn.,"  Bd.  ii,  i,  415.     See  also  Veit's  "  Handbuch,"  vol.  ii,  p.  256. 


Erosion  of  the   Cervix 


215 


be  seen  by  this  description,  there  is  no  ulceration  in  an  erosion. 
One  or  two  papillae  may  be  deprived  of  their  epithelial  covering, 
and  may  be  covered  by  granulation  cells,  but  there  is  no  ulcera- 
tion in  the  true  sense  of  the  word. 

To  the  sense  of  touch  a  cervix  the  seat  of  erosion  is  often  large 
and  soft  or  it  may  be  infiltrated  with  scar-tissue.  The  region  of 
the  OS  has  a  velvety  feel  from  the  thickened  soft  mucous  mem- 
brane, which  bleeds  easily  on  touch.  Seen  through  a  speculum 
the  vaginal  portion  around  the  external  os  is  a  deeper  red  in  color, 
and  the  epithelium  looks  thick  and  rough.      Papillary  outgrowths 


Fig.  238. — Erosion  of  cervix.  This  section  was  cut  from  a  portion  of  the  cervix 
that  should  be  entirely  covered  by  squamous  epithelium,  which  has  partly  disap- 
peared: s.e,  Remains  of  squamous  epithelium  ;  g,  cervical  glands  opening  on  surface 
(McConnell  and  J.  C.  Hirst). 


may  be  observed.  There  is  an  increase  of  the  cendcal  mucous 
discharge,  and  from  the  area  of  the  erosion  blood  may  ooze  as  a 
result  of  the  digital  examination  or  the  contact  of  the  edge  of 
the  speculum  with  the  cervix. 

The  treatment  of  erosion  is  an  application  of  nitrate  of  silver, 
20  or  60  grains  to  the  ounce,  three  or  four  times  a  week  ;  the  inser- 
tion of  boroglycerid  tampons,  and  a  daily  douche  of  boracic  acid 
solution.  The  application  of  the  positive  pole  of  a  galvanic  cur- 
rent 40  milliamperes  by  a  conical  electrode  wrapped  in  cotton 
moistened  with  salt   solution    is   often    the  quickest  and    surest 


2i6  Injuries  and  Diseases  of  the   Cervix 

means  of  curing  an  erosion.  It  may  be  necessary  to  remove  the 
cause  of  the  cervical  irritation ;  therefore  a  curetment  of  the 
uterine  cavity  and  the  operative  treatment  of  lacerations  of  the 
cervix    may   be  required. 

Inflammation  of  the  cervical  myometrium  may  be  acute  from 
infection  of  the  uterus  after  childbirth  or  operations,  in  which  case  it 
is  associated  with  acute  metritis.  More  commonly  the  inflamma- 
tion is  a  chronic  interstitial  cervicitis,  the  consequence  usually  of  in- 
juries in  childbirth.  The  result  is  a  hypertrophic  cirrhosis  indicat- 
ing amputation  of  the  cervix.  The  cervical  glands  are  usually 
obstructed  by  the  overgrowth  of  connective  tissue  around  their 
ducts,  and  there  is  a  hyperplasia  from  chronic  congestion,  so 
that  a  chronic  cervicitis  is  both  interstitial  and  glandular  or  fol- 
licular, the  distended  glands  appearing  as  vesicles  under  the 
squamous  epithelium  of  the  vaginal  portion  or  projecting  as 
small  cysts  into  the  cervical  canal. 

An  acute  exacerbation  of  congestion  may  be  combated  and 
the  chronic  condition  may  be  temporarily  improved  by  multi- 
ple punctures  in  the  cervix,  and  a  local  bloodletting;  by  pricking 
the  distended  glands  to  evacuate  them,  and  by  glycerin  tampons 
applied  to  the  cervix  and  allowed  to  remain  for  twelve  hours  at 
a  time.  A  permanent  cure,  however,  is  only  secured  by  ampu- 
tation or  by  trachelorrhaphy. 

Endocervicitis  is  most  frequently  the  result  of  lacerations  of 
the  cei'vix  or  of  gonorrhea.  It  may,  however,  be  due  to  any  of 
the  causes  that  produce  endometritis  (page  355).  In  the  endo- 
cervicitis of  an  injured  cervix  there  is  usually  a  hyperplasia  of 
the  columnar  epithelium,  which  spreads  out  from  the  os  on  the 
vaginal  portion  in  the  so-called  cervical  erosion.  The  cervical 
glands  partake  in  the  congestion,  inflammation  and  hypertrophy 
of  the  mucous  membrane,  and  excrete  an  abnormal  quantity  of 
characteristic  thick  viscid  mucus  (cervical  leukorrhea).  There 
is  also  an  extensive  round-cell  infiltration  of  the  cervical  endo- 
metrium, and  a  great  enlargement  and  increase  of  the  capillaries. 
The  membrane  is  thick  and  velvety  in  appearance,  and  within 
the  canal  is  roughened,  thrown  into  exaggerated  transverse 
folds,  projecting  into  the  canal  or  perhaps  out  of  the  os  in  poly- 
poid excrescences  which  may  develop  into  mucous  polyps  of 
considerable  size. 

The  cervical  glands  are  a  favorite  lurking-place  for  gono- 
cocci,  from  which  they  are  dislodged  with  the  greatest  difficulty, 
and  where  they  may  lie  dormant  for  a  long  time. 

The  endocervicitis  of  a  chronic  gonorrhea  produces  a  viscid 
mucopurulent  discharge  hanging  out  of  the  external  os  in  a  thick 
rope. 


Endocervicitis 


217 


The  most  satisfactory  treatment  for  endocervicitis  from  an 
injury  is  trachelorrhaphy  or  amputation  of  the  cervix. 

If  an  operation  is  contraindicated  or  impracticable  for  any 
reason,  applications  of  nitrate  of  silver,  60  grains  to  the  ounce,  or 
of  iodin,  to  the  cer\'ical  canal  and  to  the  vaginal  portion,  re- 
duce the  hyperplasia  of  the  columnar  epithelium  and  in  time 
convert  the  columnar  into  squamous  cells.  Painting  the  vaginal 
portion  with  iodin  as  a  counterirritant  and  the  application  of 
glycerin  tampons  hasten  the  cure. 

The  endocervicitis  of  gonorrhea  is  exceedingly  difficult    to 


Fig.  239. — Gonorrheal  endocervicitis. 


cure.  Application  of  nitrate  of  silver,  of  chlorid  of  zinc  in 
weak  solutions,  of  50  per  cent,  solutions  of  arg}'rol,  and  of  iodin  ; 
the  insertion  of  soluble  bougies  into  the  uterine  cavit\',  impreg- 
nated with  protargol,  argyrol,  and  other  antiseptics  and  astrin- 
gents; the  application  of  a  strong  galvanic  current  (40  milliam- 
peres)  through  the  positive  pole,  may  produce  temporary 
improvement,  but  there  is  likely  to  be  a  recurrence  of  the 
mucopurulent  discharge  over  a  period  of  years,  with  the  reap- 
pearance in  it  of  infectious  gonococci.  A  high  amputation  of  the 
cervix  may  be  necessary  to  effect  a  permanent  cure. 


2i8  Injuries  and  Diseases  of  the   Cervix 

Ulceration  of  the  Cervix. — What  is  ordinarily  and  erroneously 
•called  ulceration  of  the  cervix  is  a  hyperplasia  of  the  columnar 
epithelium.  True  ulceration,  however,  with  loss  of  substance, 
is  possible.  It  is  seen  in  prolapsus  uteri,  in  chancroids,  in 
chancre,  cancer,  sarcoma,  sloughing  fibroids,  and  tuberculosis. 

For  the  ulceration  associated  with  prolapse,  reposition  of  the 
uterus,  rest  in  bed,  applications  of  nitrate  of  silver  solution  and 
glycerin  tampons  are  indicated.  Rapid  healing  under  this  treat- 
ment is  the  rule. 

A  chancroid  of  the  cervix  should  be  eradicated  by  cauteriza- 
tion with  carbolic  acid,  fuming  nitric  acid,  a  50  per  cent,  solution 
of  chlorid  of  zinc,  or  the  actual  cautery.  Tuberculosis,  if  not 
associated  with  the  same  disease  elsewhere,  indicates  amputation 
of  the  cervix. 

A  rodent  ulcer  of  the  cervix  has  been  observed — not  can- 
cerous, but  gangrenous,  from  the  calcification  of  the  internal  iliac 
artery.  ^  The  differential  diagnosis  between  it  and  cancer  can  only 
^^e  made  by  the  microscope.  The  treatment  is  the  extirpation  of 
the  uterus. 

Tuberculosis  of  the  Cervix. — Hegar  first  called  attention  to 
cervical  tuberculosis  in  1886.  ^  Reported  cases  have  multiplied 
with  comparative  rapidity,  though  the  condition  is  rare.  More 
than  70  cases  are  now  recorded.^  Spaeth  estimates  that  cervical 
tuberculosis  constitutes  only  5  per  cent,  of  the  cases  of  genital 
tuberculosis  in  women. 

There  are  three  forms  of  cervical  tuberculosis  :  (i)  Miliary  ;  (2) 
diffuse  tubercular  infiltration  with  ulceration,  cheesy  degenera- 
tion, and  fibroid  change  ;  (3)  the  papillary  hypertrophic  tubercu- 
lar endocervicitis. 

The  miliary  form  is  associated  with  general  tuberculosis  ; 
there  are  numerous  miliary  tubercles  under  the  mucous  mem- 
brane of  the  vaginal  portion,  breaking  down  into  minute  super- 
ficial ulcers. 

The  diffuse  infiltration  with  ulceration  and  fibroid  degeneration 
is  characterized  by  hypertrophy  of  the  cervix,  distortion  of  its 
shape,  ulcers  on  the  vaginal  portion  or  in  the  cervical  canal, 
•covered  with  a  yellowish  or  grayish  deposit,  with  well-defined 
■edges,  raised  and  indurated. 

The  papillary  form  is  characterized  by  an  exaggerated  hyper- 

^Williams,  "London  Obstet.  Soc.  Tr.,"  vol.  xxvii. 

'"  Die  Entstehung,  Diagnose,  und  chirurg.  Behandl.  der  Genitaltuberculose  des 
"Weibes,"  Stuttgart,  1886. 

^Beyea,  "  Tuberculosis  of  the  Portio  Vaginalis  and  Cervix  Uteri,"  "  Amer.  Jour. 
Med.  Sci.,"  November,  1901.  Glockner,  "  Zur  papillaren  Tuberculose  der  Cervix 
uteri  u.  der  Uebertragung  der  Tuberculose  durch  die  Kohabitation,"  "  Beitrage  zui 
»Geburtsh.  u.  Gyn.,"  Hegar,  Bd.  v,  Berlin,  1901. 


Tuberculosis  of  the  Cervix  219 

plasia  of  the  cervical  endometrium  projecting  from  the  external 
OS  in  a  tumor  which  is  usually  no  larger  than  a  cherry,  but  has 
reached  the  size  of  an  apple,  rose-red  in  color,  associated  with 
papillary  erosion  of  the  vaginal  portion  for  a  distance  of  one  or 
two  centimeters  around  the  external  os,  and  enlargement,  infiltra- 
tion, and  distortion  of  the  cervix. 

Tuberculosis  of  the  cervix  may  be  secondary  or  primary. 
It  is  almost  always  the  former,  in  which  case  it  is  usually  due  to 
a  descending  infection  from  the  tubes  and  the  corporeal  endomet- 
rium. In  the  recorded  cases  of  infection  of  the  tubes  and  of  the 
cervix  without  involvement  of  the  corpus  uteri,  the  infection  has 
probably  passed  from  the  former  to  the  latter  by  the  lymph-ducts. 

There  are  four  cases  recorded  of  primary  tuberculosis  of  the 
cervix  and  six  in  which  the  cervical  infection  w^as  probably 
primary.  Primary  infection  of  the  cervix  may  be  explained  by 
the  insertion  of  infected  instruments  or  fingers,  the  contamination 
of  the  external  genitals  from  tubercular  sputum  or  discharges 
from  the  bowel;  and  to  infected  spermatic  fluid.  Glockner's 
case  was  undoubtedly  due  to  tubercular  orchitis  in  the  woman's 
husband. 

The  subjective  symptoms  of  tuberculosis  of  the  cervix  are 
not  distinctive.  There  is  usually  a  leukorrhea  tinged  with  blood, 
and  there  may  be  failing  health.  Menorrhagia  and  amenorrhea 
have  both  been  noted.  The  duration  of  the  disease  is  much 
longer  than  that  of  cancer. 

The  objective  symptoms  have  been  described  in  the  descrip- 
tion of  the  varieties  of  the  disease. 

Tuberculosis  of  the  cervix  is  most  often  confused  with  cancer. 
It  may  be  distinguished  from  malignant  disease  by  the  longer 
history,  the  lesser  degree  of  infiltration,  the  absence  of  a  large 
cauliflower  growth,  friability  of  tissue,  abundant  fetid  discharge, 
and  deep  crater-like  ulceration.  While  the  tuberculous  cervix 
may  bleed  on  touch,  there  is  not  the  tendency  to  profuse  hem- 
orrhage that  there  is  in  cancer.  The  microscopical  study  of 
tissue  removed  for  the  purpose  is  the  most  valuable  diagnostic 
test.  In  tubercular  disease  there  is  the  characteristic  histology 
of  tubercular  tissue,  tubercle  bacilli  are  usually  discoverable  in 
careful  and  repeated  examinations,  and  inoculation  experiments 
in  guinea-pigs  should  give  positive  results. 

The  treatment  of  tuberculosis  of  the  cervix  is  palliative  and 
radical.  The  former  is  called  for  if  there  is  extensive  tubercular 
disease  elsewhere  threatening  an  early  fatal  termination.  It  con- 
sists of  local  cauterization  and  disinfection. 

The  radical  treatment  is  indicated  if  it  is  possible  to  remove  all 
the  tuberculous  tissue  without  danger  of  stirring  up  tubercular 


2  20  Injuries  and   Diseases  of  the   Cervix 

processes  elsewhere  in  the  body.  If  the  tuberculosis  is  confined 
to  the  cervix,  amputation  suffices.  A  patient  with  tuberculosis 
of  the  cervix  and  of  the  tubes  has  been  cured  by  a  high  ampu- 
tation, a  curetment  and  ablation  of  the  tubes  (Beyea).  The  surest 
treatment  to  effect  a  permanent  cure  is  a  panhysterectomy  with 
removal  of  the  uterine  appendages,  by  the  vaginal  or  the  com- 
bined vaginal  and  abdominal  methods  (page  242). 

Acquired  Atresia  of  the  Cervix. — The  external  os,  the  inter- 
nal OS,  or  the  whole  cervical  canal  may  be  closed  in  consequence 
of  ulceration  of  the  cervical  mucous  membrane  and  agglutination 
of  apposed  granulating  surfaces.  The  cause  of  the  ulceration 
may  be  strong  caustics  applied  to  the  canal,  an  adynamic  or  in- 
fectious fever,  the  disturbances  of  nutrition  seen  in  prolapsus 
uteri  and  in  old  age,  the  injuries  and  inflammations  following 
childbirth  or  abortion,  malignant  growths,  or  the  intense  conges- 
tion of  pregnancy  exaggerating  an  inflammation  already  present. 
The  author  has  seen  two  cases  in  women  approaching  the  meno- 
pause without  ascertainable  cause. 

In  old  women  past  the  menopause  atresia  of  the  cervix  may 
cause  no  symptoms  unless  there  is  a  fibroid  tumor  or  a  cancer  of 
the  uterus.  In  menstruating  women  there  is  a  retention  of  blood 
(hematometra),  mucus  (hydrometra),  or  pus  (pyometra)  within 
the  womb.  Should  the  contents  of  the  uterus  be  infected  by  the 
gas  bacillus  or  by  saprophytes  causing  decomposition,  gas  may 
accumulate  within  the  uterine  cavity  (physometra).  The  following 
are  the  symptoms  of  atresia  of  the  cervix  in  menstruating  women: 
Amenorrhea,  but  the  more  or  less  regular  appearance  of  men- 
strual molimina.  The  uterus  becomes  a  cystic  tumor  the  size  of 
a  clenched  fist  or  larger.  In  physometra  it  may  be  possible  to 
elicit  a  tympanitic  note  on  percussion  or  crepitation  on  palpa- 
tion. There  is  pain  aggravated  at  the  periods  and  most  acutely 
felt,  as  a  rule,  in  one  or  both  ovarian  regions.  The  tubes  are 
gradually  distended  by  the  fluid  which  accumulates  in  them 
(hematosalpinx,  hydrosalpinx,  or  pyosalpinx). 

In  one  of  the  author's  cases  the  fluid  was  spontaneously  dis- 
charged every  three  or  four  months,  giving  the  patient  complete 
relief  for  a  time  until  the  opening  closed  again  and  the  menstrual 
blood  reaccumulated. 

If  the  external  os  is  the  site  of  the  atresia  [conghitinatio  ori- 
ficii  exterjii  titcri),  the  cervical  canal  and  the  intra-uterine  space 
become  a  single  cavity  ;  the  vaginal  portion  loses  its  nipple-like 
projection  into  the  vagina  and  is  flush  with  the  vaginal  vault.  It 
may  be  impossible  to  feel  the  external  os,  but  its  site  is  usually 
marked  on  inspection  by  a  perceptible  dimple. 

Before  undertaking  the  treatment  of  atresia  of  the  cervix,  the 


Myomata  221 

condition  of  the  tubes  should  be  ascertained  by  a  combined  ex- 
amination. If  they  are  distended,  they  should  be  removed  by 
abdominal  section  iDefore  or  immediately  after  the  evacuation  of 
the  uterus. 

To  relieve  the  distention  of  the  uterine  cavity  and  to  estab- 
lish the  patency  of  the  cervical  canal,  the  site  of  the  atresia 
should  be  punctured  by  a  trocar  or,  if  practicable,  by  a  blunt- 
pointed  instrument,  such  as  an  applicating  forceps.  The  canal 
should  then  be  dilated  with  branched  dilators,  the  uterine  cavity 
thoroughly  washed  out  with  a  large  quantity  of  boracic  acid  solu- 
tion until  it  is  completely  emptied,  and  then  packed  with  a  strip  of 
iodoform  gauze,  which  must  be  removed  in  twenty-four  hours  at 
the  most,  when  there  should  be  another  irrigation  followed  by 
fresh  packing.  After  the  second  or  third  da)'  the  passage  of 
Hegar's  graduated  cervical  bougies  should  be  begun  and  con- 
tinued daily  for  a  week  or  more,  preceded  and  followed  by  a 
uterine  irrigation.  The  patient  must  be  kept  under  observation 
for  some  months,  a  bougie  being  passed  occasionally  to  test  the 
patency  of  the  canal. 

In  old  women  without  symptoms  from  the  atresia,  in  whom 
the  condition  is  accidentally  discovered,  no  treatment  is  required. 


NEW-GROWTHS  OF  THE  CERVIX. 

Myomata  of  the  cervix  are  rare.  Winckel  declares  that  he 
never  saw  one.  Other  authors  put  their  frequency  as  compared 
with  uterine  myomata  at  5  to  8  per  cent.  Sanger  draws  a  dis- 
tinction between  infravaginal  and  supravaginal  myomata  of  the 
cervix,  pointing  out  that  the  former  grow  downward  into  the 
vagina  and  the  latter  usually  backward  into  the  retro-uterine 
connective  tissue,  between  the  peritoneum  above  and  the  vaginal 
mucous  membrane  below. 

A  myoma  occupying  one  lip  of  the  cervix  pushes  the  other 
away  from  it  as  it  grows  into  the  cervical  canal,  making  the  os 
crescentic  in  shape.  The  periphery  of  the  tumor  may  contract 
adhesions  with  the  mucous  membrane  of  the  cervical  canal  with 
which  it  comes  in  contact,  thus  in  part  obliterating  the  canal.  In 
a  case  of  the  author's  a  cervical  myoma  the  size  of  an  apple,  occu- 
pying the  left  lateral  lip  of  the  cervix,  showed  the  signs,  in  a 
microscopical  examination,  of  incipient  malignant  degeneration 
at  its  periphery  in  the  cervical  canal,  and  the  mucous  membrane 
of  the  canal  opposite  this  part  and  in  contact  with,  but  not 
adherent  to  it,  had  likewise  undergone  malignant  change  (epithe- 
liomatous).      An  enucleation  of  the  tumor  and  a  high  amputa- 


222  Injuries  and  Diseases  of  the   Cervix 

tion  of  the  cervix  cured  the  patient,  who  had  no  recurrence  five 
years  later. 

The  S}'mptoms  of  a  cervical  myoma  are  metrorrhagia,  leu- 
korrhea,  d3^smenorrhea,  sterility,  and  possibly  a  feeling  of  weight 
or  heaviness  in  the  pelvis.  A  retro-uterine  growth  may  obstruct 
or  irritate  the  rectum.  A  growth  in  the  anterior  lip  may  cause 
vesical  irritability  or  dysuria. 

The  treatment  of  a  cervical  myoma  is  enucleation,  which  is 
usually    easy.      An    incision   over    the    growth   enables    one    to 


Fig.  240. — Fibroid  polyp  protruding  from  the  cervix. 

shell  it  out  of  its  bed  without  difiRculty,  even  if  it  has  reached 
a  considerable  size.  The  cavity  may  be  packed  with  gauze  until 
it  is  closed  by  granulation,  or  its  walls  may  be  approximated  by 
sutures  if  it  is  comparatively  shallow  and  there  is  little  oozing. 

The  cervical  mucous  membrane  is  often  the  seat  of  polypoid 
tumors  consisting  of  all  its  constituent  parts, — connective,  mucous, 
and  glandular  tissues  and  blood-vessels, — one  of  these  struc- 
tures usually  predominating  over  the  others.  Mucous  polyps 
are  soft,  rich  in  glands,  covered  with  the  columnar  epithelium  of 


PLATE  H. 


Mucous  polyps  of  the  cervix. 


Myomata 


22 


Fig.    241. — Fibro-adenomatous    polyp  of   cervix:    f.t.   Fibrous    tissue;  g^,    gland- 
spaces  lined  by  typical  cervical  columnar  epithelium  (^IMcConnell  and  J.  C.  Hirst). 


Fig.  242. — Mucous  polyp  of  cervix:  ni.c.t,  mucoid  connective  tissue;  e,  epithe- 
lium (McConnell  and  J.  C.  Hirst). 


2  24  Injuries  and  Diseases  of  the  Cervix 


Fig.  243. — Ribbon-shaped  polyp  of  cervix. 


Fig.  244. — The  same,  photographed  after  removal. 


Carcinoma  of  the   Cervix   Uteri  225 

the  cervical  canal,  and  a  dark  red  in  color.  They  rarely  reach 
the  size  of  a  walnut.  After  attaining  the  .size  of  a  pea  or  a 
cherry  they  project  beyond  the  o.s,  where  they  are  easily  dis- 
covered on  a  digital  or  a  specular  examination. 

Fibroid  polyps  show  a  preponderance  of  connective  tissue, 
are  usually  spherical  in  shape,  may  reach  a  considerable  size  after 
emerging  from  the  os,  are  as  firm  as  cartilage  in  feel,  and  are 
usually  a  bright  scarlet  or  light  pink  in  color.  The  pedicle  is 
commonly  slender.  A  fibro-adenomatous  tumor  of  the  cervix 
may  be  ribbon-shaped  (Fig.  243).  Polyps  in  which  the  blood- 
vessels are  predominant  have  a  cavernous  structure  like  that  of 
the  bulbi  vestibuli  or  the  corpus  cavernosum  of  the  penis. 

The  first  symptom  of  cervical  polyps  is  ordinarily  a  menor- 
rhagia  or  metrorrhagia,  which  may  be  so  severe  that  the  patient 
is  almost  exsanguine.  There  may  also  be  rhythmical  cramps, 
expulsive  uterine  pains,  and  dysmenorrhea  before  the  polyp 
emerges  from  the  cervix.  Leukorrhea  is  common  and  dys- 
pareunia  is  a  possible  symptom  after  the  polyp  projects  from  the 
cervix.  A  cervical  polyp  before  it  appears  at  or  outside  the 
external  os  uteri  is  easily  overlooked  even  by  an  experienced 
specialist.  A  menorrhagia  may  be  treated  in  vain  by  a  curettage 
of  the  uterine  cavity,  by  intra-uterine  applications,  and  medici- 
nally until  its  cause  is  discovered  in  a  polyp  which  at  length 
protrudes  from  the  cervical  canal.  A  dilatation  of  the  canal  and 
its  digital  exploration  enable  one  to  avoid  such  a  mistake. 

Polypoid  tumors  of  the  cervix  are  best  treated  by  seizing 
them  with  a  volsella  forceps  and  making  three  or  four  sharp  turns 
of  the  instrument  on  its  long  axis,  thus  twisting  off  the  pedicle.  A 
curettage  and  an  irrigation  of  the  uterine  cavity  should  follow 
the  avulsion  of  the  tumor.  The  apparently  small  operation 
should  be  performed  with  careful  aseptic  precautions  and  should 
be  followed  by  rest  in  bed  for  at  least  forty-eight  hours.  This 
is  not  an  operation  for  office  practice.  The  author  has  seen 
severe  infection  follow  its  careless  performance.* 

It  has  been  proposed  to  remove  cervical  polyps  by  cutting 
their  pedicles  with  scissors,  the  galvanocautery  wire,  or  the  wire 
ecraseur,  but  these  methods  are  inferior  to  avulsion  by  torsion. 
If  their  base  is  too  broad  for  avulsion,  they  may  be  enucleated 
after  incision  of  the  capsule. 

Carcinoma  of  the  Cervix  Uteri. — The  uterus  is  the  com- 
monest site  of  cancer  in  the  human  body.  It  is  on  this  account 
mainly  that  women  die  of  cancer  more  than  twice  as  often  as 
men.  The  cervix  uteri  is  affected  by  cancer  more  than  four  times 
oftener  than  the  body.  Cancer  seems  to  be  on  the  increase  in 
all  civilized  countries,  and  there  are  certain  districts  where  it  is 
15 


2  26  Injuries  and  Diseases  of  the  Cervix 

unusual!}-  prevalent.  Diihrssen  states  that  the  deaths  from 
cancer  in  Germany  number  25,000  annualh'.  Another  German 
author  states  that  i  per  cent,  of  women  between  forty  and  fifty 
die  of  cancer;  that  there  are  more  deaths  from  this  cause  than 
from  labor,  and  that  the  death-rate  from  cancer  is  greater  than 
the  mortality  of  the  Franco-Prussian  war. 

Etiology. — Traumatism  and  a  consequent  long-continued  irri- 
tation and  congestion  are  the  most  important  predisposing  causes 
of  cancer  of  the  cervix.  The  vast  majority  of  cases  have  a 
history  of  five  or  more  labors.  In  nulliparous  women  there 
is  often  a  history  of    dilatation  of    the  cervix  or  other  operative 


Fig.  245. — Epithelioma  pf  cervix,  showing  pearls  :  e.n.  Epithelial  nests  ;  c.t,  connec- 
tive-tissue trabeculse  ;  e.p,  epithelial  pearls  (McConnell  and  J.  C.  Hirst). 

interference.  Heredity  plays  a  subordinate  role  as  a  predisposing 
cause.  Less  than  a  fifth  of  the  cases  have  a  family  history  of 
cancer. 

Pathology. — Cancers  of  the  cervix  may  present  one  of  four 
types — squamous-cell  carcinoma  (epithelioma),  adenocarcinoma, 
endothelioma,  and  malignant  adenoma. 

Squamous-cell  carcinoma  is  much  the  commonest,  occurring 
almost  seven  times  as  often  as  adenocarcinoma  of  the  cervix. 
Endothelioma  and  malignant  adenoma  are  exceedingly  rare. 

Sq7iaj)ioiis-cell  carcinoma  develops  from  the  squamous  epi- 
thelium of  the  vaginal  portion.      It  commonly  begins,  therefore. 


PLATE  y. 


Types  of  squamous-cell  cancer  of  the  cervix. 


Carcinoma  of  the   Cervix  Uteri 


227 


on  the  exposed  surface  of  the  cervix,  possibly  in  the  cleft  of  an  old 
cervical  tear.  The  squamous  epithelium,  however,  may  have  ex- 
tended a  considerable  distance  up  the  cervical  canal  in  a  woman 
who  has  borne  several  children.  Consequently,  an  epithelioma 
may  have  its  beginning  within  the  cervical  canal.  The  cells  pro- 
liferate with  great  rapidity,  first  causing  small  round  nodules, 
soon  ulcerating  on  the  surface  and  sending  out  innumerable 
finger-like  processes  which  coalesce  and  multiply  until  a  huge 
cauliflower  mass  may  fill  the  vaginal  vault.  The  cells  grow 
rapidly  within   the   substance   of  the   cervix,  also,    producing   a 


Fig.  246. — Scirrhous  carcinoma  of  cervix  :  e.  Epithelial  nests  ;  c.t,  connective- 
tissue  trabeculee,  predominating  and  giving  the  tumor  its  characteristic  hardness 
(McConnell  and  J.  C.  Hirst). 


growth  which  displaces  the  normal  cervical  tissue,  yellowish- 
white  on  section,  firm  as  cartilage,  made  up  of  trabeculae 
of  fibrous  tissue  in  the  meshes  of  which  are  nests  of  epitheli- 
oid cancer-cells.  The  growth  extends  outward  toward  the 
bases  of  the  broad  ligaments,  backward  along  the  uterosacral 
ligaments,  downward  under  and  along  the  vaginal  mucous  mem- 
brane, and  forward  into  the  uterovesical  connective  tissue,  involv- 
ing in  time  the  wall  and  the  mucous  membrane  of  the  bladder. 
The  uterine  mucosa  is  usually  healthy,  or  at  least  not  carcino- 
matous. There  may  be,  however,  nodes  of  epithelioma  in  the 
uterine   mucosa,  but   the   myometrium  is   more  likely  to  be  the 


2  28  Injuries  and  Diseases  of  the   Cervix 

site  of  secondary  growths.  There  is  often  endometritis,  and 
from  obstruction  of  the  cervical  canal  there  is  not  infrequently 
pyometra  and  physometra.  The  rectum  is  only  involved  late  in 
the  disease,  after  the  cancer  has  spread  down  the  posterior  vaginal 
wall,  as  the  cervix  is  separated  from  the  rectum  by  Douglas's 
pouch. 

Metastases  to  distant  organs  are  rare,  but  not  impossible.  It 
is  quite  common  to  find  nodules  of  epithelioma  near  the  fundus 
uteri,  and  in  several  cases,  as  in  one  of  the  author's  (Fig.  250), 
a  node  of  incipient  carcinoma  may  be  discovered  in  a  Fallopian 


Fig.  247. — Medullary  carcinoma  of  cervix:  c.t.  Connective-tissue  trabeculae  ; 
e.ni,  epithelial  masses,  predominating  and  giving  tumor  its  medullary  characteristics 
(McConnell  and  J.  C.  Hirst). 


tube.  The  exuberant  growth  of  a  squamous-cell  cancer  outward 
into  the  vagina  is  followed  by  necrosis  of  the  peripheral  tissues, 
which  advances  until  the  papillomatous  character  of  the  tumor 
disappears  and  its  place  is  taken  by  a  deep  ulcer  lined  with  pus, 
blood,  and  gangrenous  material.  The  vagina  ends  in  a  deep 
crater-like  pit  with  indurated,  elevated  edges. 

An  adenocarcinoma  of  the  cervix  begins  in  a  cervical  gland. 
There  is  an  enormous  hyperplasia  and  multiplication  of  the 
glands  and  their  epithelial  cells.  Teat-like  processes  of  the  latter 
project  into  the  lumen  of  the  glands,  and  there  is  the  perforation 
of  basement  membrane  and  invasion  of  surrounding  structures  by 


Carcinoma  of  the   Cervix  Uteri 


229 


the  epitheh'al  cells  characteristic  of  all  cancerous  growths.  The 
new-growth  begins  in  the  cervical  canal  or  within  the  myometrium 
of  the  cervix.  Nodules  appear  and  gradually  grow  toward  the 
cervical  canal,  in  which  they  may  lie  concealed  until  the  disease 
has  made  the  most  extensive  ravages.  Ulceration  occurs  later 
than  in  squamous-cell  carcinoma,  but  ultimately  appears,  so  that 
a  large  ulcerating  cavity  may  lie  within  an  external  os  almost  or 
quite  normal  in  appearance.  Occasionally  a  cancerous  mass  of 
considerable  size  protrudes  from  the  os  and  is  easily  detached. 
Adenocarcinoma   of  the  cervix  grows    upward  into  the  uterine 


Fig.  248. — Malignant  adenoma  of  cervix  :  g.s,  Gland-spaces,  epithelium  hy- 
pertrophied,  basement  membrane  perforated  and  glands  communicating;  /.t,  fibrous 
tissue  stroma  ;   /,  tissue  infiltrated  with  cancer-cells  (McConnell  and  J.  C.  Hirst). 


mucosa  and  myometrium,  or  outward  into  the  parametrium,  and 
downward  into  the  vagina.  The  bladder  and  rectum  may  be 
involved.  The  later  ulcerative  stages  are  the  same  in  all  forms 
of  cancer  of  the  cervix.  There  is  a  strong  tendency  to  recur- 
rence in  a  cervical  adenocarcinoma,  possibly  because  its  situation 
often  prevents  its  early  recognition  and  the  radical  operation  for 
its  removal  is  undertaken  too  late.  An  endothelioma  is  made  up 
histologically  of  tubules  and,  round  spaces  lined  with  spindle-cells. 
The  glands  are  normal;  there  are  no  teat-like  ingrowths  of  cells 
as  in  adenocarcinoma  ;  there  is  no  branching  of  the   glands,  no 


230  Injuries  and  Diseases  of  the   Cervix 

tendency  to  desquamation,  and  the  protoplasm  of  one  cell  cannot 
be  differentiated  from  that  of  the  others  (Cullen). 

A  malignant  adenoma ^  shows  a  complex  glandular  form  with 
a  single  layer  of  epithelium  lining  the  gland-spaces  ;  the  glands 
are  closely  packed  together,  penetrate  deeply  into  the  tissues, 
and  if  there  is  recurrence  after  an  operation,  the  same  glandular 
structure  is  preserved. 

All  cancers  of  the  cervix  have  a  natural  tendency  to  extend 
along  the  lymphatic  ducts  to  the  pelvic  lymphatic  glands,  but, 
owing  to  the  small  size  of  the  former  in  the  cervix  and  the  large 


Fig.    249. — Endothelial    carcinoma  of  cervix  :  e.n.   Nests  of   endothelial  cells  ;    w, 
cervical  myometrium  (McConnell  and  J.  C.  Hirst) . 

size  of  the  epithelial  cells,  the  lymphatics  of  the  pelvis,  accord- 
ing to  Winter,  ^  are  only  involved  after  the  cancer  has  extended  to 
the  pelvic  connective  tissue,  in  which  large  ducts  may  be  invaded 
and  the  corresponding  glands  affected.  The  usual  course  of  the 
disease  is  to  the  two  glands  on  either  side  of  the  cervix  if  they 
exist ;  along  the  lymphatic  ducts  to  the  iliac  glands  at  the  bifur- 
cation of  the  iliac  arteries,  or  to  the  lumbar  glands  in  front  of 
the  aorta.  The  retroperitoneal  pelvic  and  abdominal  lymphatic 
glands  may  be  enlarged,  congested,  and  inflamed  in  association 

iRuge  and  Veit,  "  Zeitschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  vii,  p.  170. 
2  "  Ueber  die  Recidive   des   Uteruskrebses,  insbesondere  iiber    Impfrecidive," 
George  Winter,  Stuttgart,  1893. 


Carcinoma  of  the   Cervix  Uteri  231 

with  carcinoma  of  the  cervix  uteri  without  being  themselves  can- 
cerous. 

Clinical  History  and  Symptoms.— Cancer  of  the  cervix  is  most 
commonly  seen  in  women  between  forty  and  fifty,  or  after  the 
menopause.  It  has  been  observed  in  a  woman  seventy-five  years 
old,  and  an  adenocarcinoma  has  been  found  in  a  child  of  eight. 
In  a  case  of  the  author's  in  the  Howard  Hospital  there  was  a 
recurrence  after  vaginal  hysterectomy  in  a  woman  not  quite 
twenty-five.  In  a  colored  woman  of  twenty-seven  years  a 
vaginal  hysterectomy  was  performed  for  epithelioma  of  the  cervix, 
and  one  of  twenty -four  was  discharged  as  inoperable. 

The  first  symptom  to  attract  the  patient's  attention  is  a  bloody 
discharge.  There  may  be  simply  a  menorrhagia  at  first,  but 
there  is  soon  an  intermenstrual  bleeding,  especially  after  coitus  or 
some  unusual  exertion,  which  is  due  to  the  friable  character  of 
the  delicate  finger-like  processes  constituting  the  exuberant  or 
cauliflower  growth  of  the  earlier  period  of  the  disease. 

The  bleeding  at  first  is  moderate  in  amount  and  may  not 
alarm  the  patient  or  even  attract  her  attention.  If  it  occurs  after 
the  menopause,  it  is  often  welcomed  as  a  sign  of  continued  or 
returning  sexual  activity.  Preceding,  accompanying,  or  follow- 
ing the  bloody  discharge  there  appears  a  leukorrhea,  at  first 
watery  in  character,  later  of  a  thicker  consistency,  more  purulent, 
containing  necrotic  fragments,  and  soon  acquiring  a  peculiarly 
offensive  odor,  which  is  often  described  as  characteristic  of  can- 
cer, but  which  is  due  to  the  sloughing  of  the  cancerous  mass, 
and  is  observed  also  in  a  sloughing  myoma. 

Many  women  present  an  appearance  of  perfect  health  until 
comparatively  late  in  the  disease.  In  some  the  cancerous 
cachexia  appears  early.  In  all  it  develops  as  the  disease  pro- 
gresses. The  weight  diminishes,  the  color  is  a  peculiar  yellow- 
ish or  grayish-white,  the  appetite  is  poor,  and  the  general 
strength  fails.  The  cachexia  is  explained  by  the  hemorrhage 
and  a  septic  intoxication.  The  blood  becomes  poor  in  hemo- 
globin and  red  blood-corpuscles.  There  is  a  slight  leukocytosis. 
There  is  said  be  an  abnormal  excretion  of  nitrogen  from  the 
body,  much  in  excess  of  what  is  ingested.  Pain  is  scarcely  ever 
noted  until  the  disease  is  far  advanced  and  has  invaded  other 
pelvic  structures  besides  the  uterus.  It  may  then  be  excruciating 
and  scarcely  controllable  by  drugs. 

The  excretion  of  urine  is  commonly  diminished  by  obstruc- 
tion of  the  ureters,  as  the  cancerous  infiltration  surrounds  them. 
There  is  hydronephrosis  and  usually  uremia,  which  mercifully 
terminates  the  patient's  sufferings  in  the  majority  of  cases. 

The  bladder-wall  and  the  vesical  mucous  membrane  in  time 


232 


Injuries  and  Diseases  of  the   Cervix 


exhibit  nodes  of  cancer,  rapidly  breaking  down  and  establishing 
by  ulceration  a  vesicovaginal  fistula.  Late  in  the  progress  of 
the  disease,  after  the  posterior  vaginal  Avail  is  extensively  in- 
volved, the  rectum  may  be  perforated,  so  that  there  is  a  cloaca  in 
which  are  mingled  feces,  urine,  and  the  fetid  discharges  from  the 
cancer. 


Fig.  250. — Squamous-cell  cancer  of  cervix,  papillary  growth. 


Fig.  251. — Incipient  squamous-cell  cancer  of  the  cervix. 


The  uterine  wall,  especially  posteriorly  near  the  lower  uterine 
segment,  may  be  perforated,  but  the  general  peritoneal  cavity  is 
shut  off  b}^  adhesions,  and  death  from  peritonitis  is  rare. 

The  diagnosis  of  cervical  cancer  is  made  by  the  patient's  his- 
tory, her  appearance,  the  odor  of  the  discharge,  a  digital  and 
specular  examination  of  the  vagina  and  cervix,  and  a  microscop- 


Carcinoma  of  the  Cervix  Uteri 


Fig.  252. — Prolapse  of  the  uterus  and  epithelioma  of  the  cervix. 


Fig.  253. — Squamous-cell  cancer  of  cervix,  ulcerative  stage. 


234 


Injuries  and  Diseases  of  the  Cervix 


ical  examination  of  a  portion  of  the  diseased  cervix  removed  for 
the  purpose.  Bleeding  from  the  vagina  in  a  woman  of  middle  or 
advanced  age  should  always  excite  suspicion  of  uterine  cancer, 


Fig.  254. — Incipient  adenocarcinoma  of  cervix. 


Fig.  255. — Epithelioma  of  cervix. 


and  should  indicate  a  careful  examination  without  delay.  Thou- 
sands of  lives  might  be  saved  if  the  significance  of  this  symptom 
were  better  understood  by  women.  It  is  a  physician's  duty  to 
inculcate  this  lesson  in  his  patients,  and  to  combat  the  pernicious 


Carcinoma  of  the  Cervix   Uteri 


235 


notion  that  metrorrhagia  is  a  natural  precursor  or  concomitant 
of  the  menopause  which  need  cause  no  concern.      If  the  patient 


Fig.  256. — Squamous-cell  cancer  of  cervix. 


Fig.  257. — Squamous-cell  cancer  of  cervix,  papillary  growth. 


exhibits  cachexia  and  gives  a  history  of  decreased  weight  in  addi- 
tion  to  metrorrhagia,  the  suspicion  of  cancer  is   strengthened. 


236 


Injuries  and  Diseases  of  the  Cervix 


The  foul  odor  of  the  discharge  has  a  certain  diagnostic  value.  It 
may  be  due  to  a  sloughing  myoma,  a  piece  of  placenta,  or  a  for- 
eio-n  body,  such  as  gauze,  left  in  the  vagina  a  long  time,  but  the 


Fig.  258. — Cauliflower  epithelioma  of  cervix. 


^ 


Fig.  259. — Squamous-cell  cancer  of  cervix,  ulcerative  stage. 


commonest  explanation  is  the  sloughing  of  a  cancer.  On  digital 
examination  the  find  differs  according  to  the  stage  of  the  disease. 
In  the  beginning  nodules  may  be  felt ;  the  cervix  is  usually 
enlarged  and  its  consistency  is  unnaturally  firm.  Ulcers  with 
indurated  edges  may  be  appreciated,  or,  most  commonly,  exuber- 


Carcinoma  of  the  Cervix  Uteri 


^0/ 


ant  papillomatous  growths  are  detected.  The  digital  examina- 
tion causes  bleeding,  as  a  rule,  sometimes  quite  profuse  ;  the 
finger-tip  at  least  is  stained  with  blood  after  the  examination. 

In  later  stages  the  recognition  of  cervical  cancer  is  easy.  A 
huge  cauliflower  growth  fills  the  vaginal  vault,  from  which  large 
pieces  may  be  removed  by  the  examining  finger,  or  there  is  a 
deep  crater-like  ulcer  with  indurated  edges  occupying  the  situa- 
tion of  the  cervix.  If  the  broad  ligaments  are  involved,  they  are 
board-like  in  feel,  fixing  immovably  the  vaginal  vaults  laterally 
and  the  uterus.  The  involvement  of  the  bladder  may  be  detected 
by  the  infiltration  of  the  anterior  vaginal  wall  and  subjacent  tis- 
sues, the  history  of  frequent  urination,  and  a  cystoscopic  exam- 
ination in  which  nodes  of  cancer  may  be  seen  in  the  vesical 
mucous  membrane.  Later  a  vesicovaginal  fistula  and  incon- 
tinence of  urine  indicate  the  cancerous  ulceration  of  the  bladder- 
wall. 

In  an  adenocarcinoma  of  the  cervix  it  may  be  necessary  to 
insert  the  forefinger  in  the  cervical  canal.  Hard  nodules  and 
deep  fissures  are  felt ;  the  elasticity  of  the  cervix  is  lost ;  the  tis- 
sue is  hard  and  at  the  same  time  brittle  ;  deep  ulceration  may  be 
detected  ;  bleeding  is  excited  by  the  examination,  and  masses  of 
the  growth  may  perhaps  be  removed  by  the  tip  of  the  forefinger, 
but  it  is  not  so  friable  as  an  epithelioma. 

The  size  and  condition  of  the  uterus  should  always  be  taken 
into  account.  If  it  is  enlarged,  its  cancerous  involvement,  preg- 
nancy, or  pyometra  should  be  thought  of  On  a  specular  ex- 
amination in  an  early  stage  of  the  disease,  the  enlarged  cervix,  its 
indurated  appearance,  nodules  under  the  mucous  membrane, 
which  may  be  blue  in  color,  glazed  and  stretched  as  though 
ready  to  burst,  indicate  an  incipient  carcinoma.  The  papilloma- 
tous outgrowths  a  little  later  are  pathognomonic.  A  large  cauli- 
flower mass  is  unmistakable.  Extensive  ulceration  is  extremely 
suspicious,  to  say  the  least,  for  true  ulceration  of  the  cervix  is 
exceedingly  rare  except  in  cancer.  The  appearance  presented 
after  necrosis  has  begun  is  quite  distinctive.  Large  pits  in  the 
exuberant  mass  are  seen,  lined  with  yellowish-green  pus  and 
necrotic  material.  In  an  adenocarcinoma  of  the  cervix  the 
appearance  presented  in  a  specular  examination  may  not  indicate 
the  true  nature  or  the  extent  of  the  disease.  The  cervix  and 
internal  os  may  appear  to  be  normal.  Later  the  vaginal  vault  is 
puckered  and  irregularly  elevated  by  nodular  growths  ;  the  os 
is  represented  by  an  irregularly  shaped  opening  or  may  be 
invisible.  In  all  cancers  of  the  cervix,  the  digital  is  more  valuable 
than  the  specular  examination.  In  case  of  doubt  as  to  the  nature 
of  a  disease  of  the  cervix,  a  piece  of  tissue  of  considerable  size 


238  Injuries  and   Diseases  of  the  Cervix 

should  be  removed  from  the  most  suspicious  area  for  microscop- 
ical examination.  It  is  usually  better  to  anesthetize  the  patient. 
The  tissue  to  be  removed  is  transfixed  with  a  tenaculum  and  is 
cut  out  with  heavy  sharp-pointed  scissors  curved  on  the  flat.  If 
there  is  good  reason  to  believe  the  disease  cancerous,  it  is  not 
infrequently  more  convenient  for  the  surgeon  and  better  for  the 
patient  to  be  prepared  for  a  radical  operation,  to  have  a  rapid 
diagnosis  of  the  nature  of  the  growth  made  by  the  freezing 
process,  and  to  perform  at  once  a  hysterectomy  if  the  patholo- 
gist's report,  made  within  five  or  ten  minutes,  is  unfavorable. 


^ 

i^ 

i 

mfr^^ 

^^_^^^^H 

1 

BQ 

■|^H 

J^     9 

^^1 

1^^^ 

up^Pkn 

^^H 

K^Hk 

'^jy^^ 

^^5 

H 

Ift 

^^ 

'^SBg 

^ 

7 

Fig.  260. — Jung-Hobel  freezing  microtome  ;   ether  spray. 


Technic  of  Rapid  Diagnosis  by  the  Freezing  Microtome. — ^ppa- 

ratus. — The  apparatus  necessary  for  the  work  consists  of  (l)  a  Jung-Hobel  freezing 
microtome,  using  the  ether  spray  or  the  COj  apparatus  ;  (2)  5  per  cent,  formalin  solu- 
tion ;  (3)  a  sharp  knife  with  bone  or  ebony  handle  ;  and  (4)  the  usual  spatulas, 
needles,  staining  fluids,  etc.,  necessary  in  any  microscopical  section  work. 

The  ether  spray  has  the  advantage  over  the  COj  apparatus  of  being  much  more 
portable,  and  more  easily  regulated.  It  has  the  disadvantage  that  it  does  not  freeze- 
the  tissues  well  in  very  hot  weather. 

Certain  tissues  freeze  and  cut  much  better  than  others.  Pieces  of  cervix,  uterus, 
solid  growths,  like  carcinomata  and  sarcomata,  as  a  rule  cut  well.  On  the  other 
hand,  it  is  difficult  to  get  satisfactory  frozen  sections  of  endometrium,  mucous  polyps, 
or  tissue  containing  a  large  amount  of  fat  or  blood.     It  is  usually  necessary  to  cut  such. 


Carcinoma  of  the  Cervix  Uteri  239 

sections   thick.     Whenever  possible,  the  microtome  should  be  set  at  25-30 /i  to  get 
the  best  results. 

Technic. — The  apparatus  is  prepared  as  shown  in  figure  260.  The  tissue  to  be 
examined  is  cut  into  pieces  not  over  Yi  inch  long,  |<  inch  broad,  by  ^  inch, 
thick.  It  is  better  to  have  them  smaller  than  this,  but  certainly  not  larger,  as  it  only 
adds  to  the  difficulty  of  freezing.  The  tissue  to  be  frozen  is  placed  on  the  platform  of 
the  microtome  and  is  held  down  upon  it  by  pressure  with  the  bone  or  ebony  handle  of  a 
knife  or  other  suitable  instrument,  and  the  spray  is  started  and  kept  going  by  means 
of  the  bulb.  It  is  better  not  to  use  a  steel  instrument  to  hold  the  tissue  on  the  stage, 
as  the  metal  absorbs  the  cold  and  delays  freezing.  As  soon  as  the  tissue  is  frozen 
fast  to  the  stage,  the  upper  part  is  cut  away,  leaving  a  thickness  of  not  over  y%  inch. 
The  stage  is  then  screwed  up  by  means  of  the  micrometer  screw  until  the  knife 
just  touches  the  tissue.  The  micrometer  screw  is  then  set  at  the  desired  thickness 
and  the  sections  are  cut,  swinging  the  knife  by  means  of  the  handle.  The  stage  is 
raised  the  proper  distance  between  each  section  by  the  small  catch  under  the  handle 
of  the  instrument.  Probably  the  most  difficult  part  of  the  whole  procedure  is  to  judge 
the  degree  to  which  the  tissue  should  be  frozen.  This  can  only  be  done  by  practice. 
When  the  tissue  is  frozen  too  hard,  it  cuts  in  ridges  ;  so  it  should  be  kept  just  short 
of  this  point,  that  the  sections  will  cut  smoothly.  The  sections,  as  they  are  cut, 
are  wiped  off  the  knife-blade  with  the  finger  and  placed  in  5  per  cent,  formalin  solu- 


Fig.  261. — Incipient  malignant  adenoma  of  cervix,  appearing  as  a  small  nodule, 
within  the  cervical  canal. 


tion.  They  are  left  in  this  for  three  or  four  minutes,  to  harden  them  so  that  subse- 
quent manipulations  will  not  tear  them.  Then  the  section  to  be  examined  is 
carefully  straightened  out  on  a  spatula,  stained  for  one  Or  two  minutes  in  Delafield's 
hematoxylon,  washed  for  one  minute  in  water,  and,  if  the  diagnosis  be  desired  in  a 
hurry,  mounted  in  glycerin  and  examined.  If  there  be  no  need  of  great  hurry,  three 
or  four  minutes  extra  can  be  allowed  ;  it  is  often  safer  to  counterstain  the  section  in 
eosin  and  then  dehydrate  clear  and  mount  in  the  ordinary  way.  With  a  little  practice, 
a  diagnosis  can  usually  be  given  in  ten  minutes  from  the  time  the  tissue  is  removed 
from  the  patient,  or  often  in  an  even  shorter  time.  Time  can  be  .saved  by  using 
concentrated  instead  of  the  usual  dilute  stains.  In  any  case  it  is  necessary  to  re- 
member that  these  frozen  sections  stain  more  readily  and  deeply  than  those  hardened 
in  alcohol,  and  they  must  be  watched  accordingly.  A  frozen  section  too  deeply 
stained  is  useless  for  diagnostic  purposes. 

It  may  be  necessary  to  amputate  the  cervix  in  order  to  study 
its  condition  satisfactorily  and  to  arrive  at  a  correct  diagnosis. 
The  incipient  adenocarcinoma  represented  in  figure  261  would 
scarcely  have  been  detected  in  any  other  way. 


240  Injuries  and  Diseases  of  the  Cervix 

The  differential  diagnosis  of  cancer  of  the  cervix  and  such 
conditions  as  cervical  tears  and  cicatricial  infiltration,  hypertrophy, 
simple  ulceration,  ectropion  and  erosion,  polyps,  granular  inflam- 
mation of  the  vaginal  portion,  myomata,  sarcomata,  condylo- 
mata, syphilis,  and  tuberculosis  should  never  be  very  difficult. 
Simple  ulcers  and  erosions  are  not  extensive,  yield  rapidly  to 
local  treatment,  and  there  is  no  infiltration  of  surrounding  tissues. 
Hypertrophy,  old  lacerations,  and  cicatricial  infiltration  do  not 
cause  ulceration.  Polyps  and  myomata  are  not  ulcerated,  and 
are  covered  with  a  normal  pink  mucous  membrane  or  the  deeper 
red  membrane  of  the  cervical  canal  ;  there  is  no  papillomatous 
outgrowth  and  no  infiltration  of  surrounding  or  subjacent  tissue. 


Fig.  262. — Malignant  adenoma  of  cervix.      Same  as  figure  261,  the  cervix  laid  open. 

A  sloughing  myoma  is  often  mistaken  for  a  cancer,  but  there  is 
no  infiltration  around  its  base,  no  papillary  outgrowths  on  its 
surface,  and  no  deep  ulceration,  although  the  tissue  is  friable  and 
can  be  removed  sometimes  in  large  pieces  by  the  finger-tip.  The 
microscopical  examination,  if  necessary,  is  conclusive. 

Granular  vaginitis  has  a  distinctive  appearance  not  at  all  sug- 
gestive of  cancer,  not  ulcerative  in  character,  affecting  the  vaginal 
portion  of  the  cervix  and  the  vaginal  mucous  membrane,  usually 
due  to  gonorrhea  or  occurring  in  pregnancy,  and  with  no  infiltra- 
tion of  subjacent  tissue.  Condylomata  of  the  vaginal  vault  and 
cervix  are  extremely  rare.  The  author  has  seen  but  one  case. 
There  is  a   large  papillomatous   growth,  but  the  surface  is  not 


Carcinoma  of  the  Cervix  Uteri  241 

ulcerated,  the  color  is  a  Hght  pink,  the  individual  papillomata  are 
separated  from  one  another,  the  intervening  mucous  membrane 
is  perfectly  healthy,  and  there  is  not  the  slightest  infiltration  sur- 
rounding or  underlying  the  narrow  bases  of  the  pedunculated 
warty  masses. 

Sarcoma,  tuberculosis,  and  syphilis  are  not  so  easily  distin- 
guished from  cancer.  A  chancre,  syphilitic  ulceration,  or 
a  gumma  either  heals  spontaneously  or  yields  to  specific  treat- 
ment. A  sarcoma  may  present  a  distinctive  appearance,  but  a 
microscopical  examination  may  be  necessary  to  determine  its 
character.  It  is  a  very  rare  growth,  and  the  law  of  chance  is 
against  a  malignant  tumor  of  the  cervix  being  of  this  type. 

Tuberculosis  has  a  characteristic  appearance  and  may  have 
the  distinctive  history  of  extension  from  tuberculosis  of  the 
uteiine  cavity  or  of  infection  from  tuberculosis  of  the  male  organ 
(page  218).  The  microscope  and  inoculation  experiments  may 
be  necessary,  however,  to  arrive  at  a  correct  diagnosis.  It  must 
be  remembered  that  cancer  of  the  cervix  may  be  associated  with 
tuberculosis  of  the  uterus. 

The  treatment  of  carcinoma  of  the  cervix  uteri  is  the  complete 
removal  of  the  uterus  with  its  appendages.  If  the  carcinoma  has 
extended  to  the  peri-uterine  connective  tissue,  the  bladder,  the 
vagina,  the  rectum,  and  the  retroperitoneal  lymphatic  glands, 
recurrence  is  practically  certain  ;  therefore  palliative  treatment 
only  is  justifiable  to  remove  the  sloughing  cancerous  mass,  to 
destroy  as  much  of  the  carcinomatous  growth  as  possible,  to 
postpone  the  fatal  issue,  and  to  afford  a  comparative  euthanasia. 
Persistent  and  daring  attempts  have  been  and  are  being  made  to 
save  patients  in  whom  a  cancer  has  extended  beyond  the  uterus 
itself,  by  the  removal,  along  with  the  uterus,  of  a  portion  of  the 
vagina,  the  bladder,  the  pelvic  lymphatic  glands,  fat  and  con- 
nective tissue  ;  but  the  results  are  not  encouraging.  An  ex- 
tension of  the  disease  to  the  vaginal  vaults  is  readily  dealt 
with  by  their  removal  with  the  cervix  and  uterus,  but  more  ex- 
tensive involvement  and  the  exsection  of  neighboring  organs  and 
tissues  have  simply  demonstrated  the  possibilities  of  modern 
surgery  to  eradicate  anything  but  a  vital  organ  without  an  im- 
provement in  the  ultimate  results  of  cervical  cancer.  It  is  not 
the  extensive  but  the  early  operation  for  the  disease  that  promises 
better  results  in  the  future. 

If  there  is  no  demonstrable  involv^ement  of  the  broad  liga- 
ments, the  vesico-uterine  pouch  and  the  bladder-wall,  the  utero- 
sacral  Ugaments,  the  rectum,  or  the  pelvic  lymphatic  glands,  the 
case  is  a  suitable  one  for  hysterectomy.  The  uterus  is  freely 
mobile,  there  is  no  infiltration  to  be  felt  beyond  the  cervix  in 
16 


242  Injuries  and   Diseases  of  the  Cervix 

either  a  vaginal  or  a  rectal  examination,  there  are  no  vesical 
symptoms,  and  the  cystoscope  shows  no  cancerous  nodules  or 
ulcerations  in  the  vesical  mucous  membrane.  It  must  be  remem- 
bered that  salpingitis  with  pelvic  peritonitis  and  adhesions  is  not 
uncommon  in  association  with  cervical  cancer,  and  that  there  may 
be  an  inflammatory  and  not  a  cancerous  infiltration  of  the  pelvic 
connective  tissue.  The  former,  however,  is  not  so  stony  hard, 
is  not  so  extensive,  and  may  appear  at  a  stage  of  the  cervical 
cancer  when  involvement  of  the  peri-uterine  connective  tissue 
would  be  unlikely.  Mere  inflammatory  infiltration  of  the  peri- 
uterine tissue  does  not  contraindicate  hysterectomy. 

The  removal  of  the  uterus  being  determined  upon,  the  ope- 
rator ma\^  choose  a  vaginal  operation  alone,  an  abdominal  ope- 
ration, or  a  combined  vaginal  and  abdominal  operation.  The  last 
is  preferable  in  the  majority  of  cases.  It  enables  one  to  destroy 
the  infectious  character  of  the  cancer  for  the  time,  to  make  the 
vaginal  incisions  in  the  most  convenient  and  effective  manner,  to 
separate  the  attachment  of  the  uterus  ^\'ithin  the  pelvis  with  the 
least  danger,  immediate  and  remote,  of  hemorrhage  and  of 
injuring  or  ligating  the  ureters.  It  insures  the  entire  removal  of 
the  uterine  appendages,  in  which  there  may  be  incipient  carci- 
noma, and  it  gives  an  opportunity  to  inspect  the  organs  and 
tissues  within  the  pelvis  and  abdomen.  In  short,  the  combined 
vaginal  and  abdominal  panhysterectomy  unites  the  advantages 
of  both  and  avoids  the  disadvantages  of  each  method  of  ope- 
rating. 

Paiihvstercctoiny  by  the  Combined  Vaginal  and  Abdominal 
Methods. — The  patient  is  prepared  for  an  abdominal  and  a 
vaginal  operation  (page  600).  She  is  arranged  on  the  table  for  a 
vaginal  operation.  The  cervix  is  exposed  b}'  four  vaginal  retrac- 
tors— an  anterior,  a  posterior,  and  two  narrow  short-bladed  lateral 
retractors.  The  cervix  is  seized  with  a  Landau  tenaculum  forceps, 
steadied,  and  pulled  down.  With  a  serrated  curet  and  scissors 
all  the  cancerous  mass  that  can  easily  be  removed  is  scraped  or 
cut  away.  The  remainder  of  the  tumor  is  burned  with  a  Paque- 
lin  cautery  or  an  electrocautery  point  until  it  is  thoroughly 
charred.  By  the  use  of  the  cautery  the  sloughing  tumor  is  ster- 
ilized and  the  danger  of  implantation  metastasis  or  infection  is 
minimized.  A  circular  incision  is  made  in  the  vaginal  vault 
around  the  cervix  with  an  electrocautery  knife,  as  far  as  possible 
from  the  cancer.  The  cervi.x  is  pulled  down  while  the  surround- 
ing tissues  are  stripped  from  it,  mainly  by  a  blunt  dissection, 
until  the  peritoneum  and  the  bases  of  the  broad  ligaments  are 
reached.  The  anterior  cul-de-sac  is  opened  by  catching  the 
peritoneum  with  a  hemostat  and  perforating  it  with  the   finger- 


Carcinoma  of  the  Cervix  Uteri  243 


Fig.  263.— Incision  around  the  cancerous  cervix  for  tlie  removal  of  tlie  uterus. 


Fig.  264. — Opening  the  peritoneum  of  the  vesico-uterine  pouch. 


244  Injuries  and   Diseases  of  the   Cervix 

tip  or  the  point  of  a  scissors  between  the  hemostat  and  the 
uterus.  The  peritoneum  is  then  torn  or  cut  to  the  anterior  sur- 
faces of  the  broad  Hgaments.  The  posterior  cul-de-sac  is  opened 
in  the  same  way  between  a  hemostat  placed  close  to  the 
rectum  and  the  uterus,  and  the  opening  is  enlarged  to  the 
broad  ligaments.  The  vagina  is  packed  with  gauze,  the  instru- 
ments used  in  the  vaginal  operation  are  laid  aside,  the  operator 
and  his  assistants  change  their  gloves.  The  patient  is  arranged 
on  the  table  for  an  abdominal  section.  The  abdomen  is  opened 
in   the    median    line  by  a  long  incision.      The    fundus    uteri    is 


Fig.  265. — Opening  the  posterior  cul-de-sac. 


seized  with  tenaculum  forceps  and  pulled  to  one  side.  The 
ovarian  artery  and  the  round  ligament  on  the  opposite  side 
are  ligated  with  silk  ligatures.  A  clainp  is  placed  on  the 
broad  ligament  above  the  ligatures  so  that  its  whole  width  is 
included.  A  hemostat  is  fastened  to  the  broad  ligament  just 
above  the  ligature  on  the  ovarian  artery,  and  the  broad  ligament 
is  cut  with  scissors  between  the  hemostat  and  the  clamp  until  the 
round  ligament  is  severed.  The  uterus  now  being  forcibly  drawn 
to  the  opposite  side,  the  incision  made  in  the  vaginal  operation 
through  the  anterior  cul-de-sac  is  lengthened  bv  a  cut  through 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     245 

the  peritoneum  to  join  the  incision  through  the  broad  Hgament 
which  has  severed  the  round  hgament.  By  a  blunt  dissection 
of  the  peritoneal  flap  on  the  anterior  base  of  the  broad  ligament 
the  ureter  and  the  uterine  artery  may  be  exposed.  The  artery 
may  be  ligated  on  the  outer  side  of  the  ureter,  if  it  is  desired  to 


Fig.  266. — Ligation  of  ovarian  artery  and  of  round  ligament. 


Fig.  267. — Incision  of  broad  ligament  and  ligation  of  uterine  artery  in  combined 

hysterectomy. 


remove  as  much  of  the  connective  tissue  around  the  cervix  as 
possible,  and  it  is  always  well  to  do  so.  The  artery  is  cut  on 
the  distal  or  inner  side  of  the  ligature  and  the  lateral  attachments 
of  the  cervix  are  severed.  The  same  procedure  is  carried  out  on 
the  opposite  side,  whereupon  the  uterus  is  freed  and  lifted  out 


246  Injuries  and   Diseases  of  the   Cervix 

of  the  abdomen.  An  examination  is  made  of  the  ihac  lymphatic 
glands.  They  are  not  likely  to  be  enlarged  if  the  case  is  an 
operable  one.  If  they  are,  they  should  be  removed  by  slitting 
the  peritoneum  over  them  upon  a  grooved  director  and  carefully 
dissecting  them  out  with  the  greatest  care  not  to  injure  the 
important  blood-vessels  upon  which  they  lie. 

It  is  a  moot  question  whether  the  lymphatic  glands  should 
always  be  removed,  as  in  the  operation  for  cancer  of  the  breast. 
It  has  been  enthusiastically  advocated  and  uniformly  practised  by 
a  few  operators  recently,  but  it  is  too  soon  to  judge  of  the  results. 
So  far  as  our  present  knowledge  goes,  when  the  lymphatics  are 
involved  there  is  sure  to  be  a  recurrence,  and  the  case  is  really 
inoperable  ;  but  any  attempt  to  improve  the  ultimate  results  of 
hysterectomy  for  cancer  of  the  cervix  seems  justifiable  in  the 
present  unsatisfactory  status  of  the  operation. 

It  is  urged  by  Kelly  and  his  followers  that  the  insertion  of 
bougies  into  the  ureters  is  a  desirable  prerequisite  to  hysterec- 
tomy for  cancer  by  any  method,  and  in  selected  cases  it  is  well 
worth  remembering  ;  but  it  is  not  really  necessary  if  the  disease 
has  not  extended  beyond  the  cervix ;  it  has  not  always  been  pos- 
sible to  catheterize  both  ureters  in  these  cases,  and  the  presence 
of  bougies  in  the  ureters  has  not  prevented  their  ligation  or 
inclusion  in  a  clamp.  ^ 

After  the  removal  of  the  uterus  and  the  examination  of  the 
pelvic  lymphatic  glands,  the  posterior  and  anterior  vaginal  walls 
are  united  with  two  or  three  interrupted  catgut  sutures ;  the  peri- 
toneum attached  to  the  bowel  is  united  to  that  attached  to  the 
bladder  by  a  few  interrupted  catgut  sutures.  The  abdominal 
wound  is  closed.  The  vaginal  packing  is  then  removed,  as  it  has 
been  soaked  with  blood,  and  is  replaced  with  fresh  gauze,  which 
is  removed  in  forty-eight  hours. 

An  important  modification  of  this  technic  has  been  recently 
advocated  and  practised  by  A.  J.  Downes.  Instead  of  ligatures 
on  the  vessels  of  the  broad  ligament,  the  whole  broad  ligament 
is  compressed  and  cooked  by  the  Downes  electrothermic  angio- 
tribe  (page  589).  Outlying  nests  of  cancer  cells  are  thus  likely 
to  be  destroyed.  2 

Vaginal  Hysterectomy. — The   vaginal    method    is    preferable 

1  Cullen,  op.  cit.  Both  accidents  occurred  in  Kelly's  clinic  in  spite  of  bougies  in 
the  ureters. 

2  1  have  used  this  method  in  both  carcinomata  and  sarcoma  of  the  uterus  and 
like  it.  It  promises  more,  I  think,  than  any  recent  modification  of  the  technic  of 
hysterectomy  for  malignant  disease.  It  is  somewhat  safer,  or  at  least  gives  the 
operator  a  sense  of  security  to  expose  the  ureter  and  to  ligate  the  uterine  artery. 
The  cautery  clamp  is  then  applied  to  the  inner  side  of  the  ureter  and  the  ligature. 
The  ovarian  artery  may  be  safely  trusted  to  the  electrothermic  pressure  and  requires 
no  ligature. 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     247 

if  the  woman  is  very  fat,  if  the  operation  promises  to  be 
particularly  easy  and  rapid,  and  if  the  patient's  condition  is  not 
good. 

The  woman  is  always  prepared  for  an  abdominal  section  in 
case  of  unforeseen  difficulties  in  the  vaginal  operation  which 
might  necessitate  opening  the  abdomen. 

The  first  steps  of  the  operation  are  the  same  as  those  described 
in  the  combined  method.  After  opening  the  anterior  and  pos- 
terior cul-de-sac  and  freeing  the  lateral  attachments  of  the  cervix 
up  to  the  uterine  artery,  the  uterus  is  cut  in  half  by  inserting 
one  blade  of  a  strong  straight-bladed  scissors  in  the  cervix 
and  placing  the  other  upon  the  anterior  surface  of  the  uterus  ;  as 
the  uterus  is  cut  it  is  pulled  downward  by  tenaculum  forceps 
fastened  to  its  anterior  surface  on  both  sides  of  the  median  line, 
which  are  shifted  upward  until  the  fundus  appears  in  the  vagina 
through  the  opening  in  the  anterior  cul-de-sac;  meanwhile 
Landau's  ecarteurs  are  inserted  in  the  pelvic  cavity  and  are  pressed 
upward  and  outward  by  assistants,  to  crowd  the  ureters  out  of  the 


Fig.  268. — Ecarteur,  for  distending  the  wound  and  guarding  the  ureter. 

way.  When  the  fundus  is  reached,  the  scissors  cut  the  posterior 
uterine  wall  from  the  fundus  toward  the  cervix,  the  blade  origi- 
nally inserted  in  the  uterine  cavity  still  remaining  there  until 
the  uterus  is  completely  divided.  One-half  is  allowed  to  retreat 
within  the  pelvic  cavity.  The  other  is  held  firmly,  fundus  down- 
ward, by  a  forceps.  The  ovary  and  tube  on  this  side  are  freed 
if  they  are  adherent,  and  are  pulled  inward  and  downward, 
exposing  the  free  edge  of  the  broad  ligament  and  the  infundib- 
ulopelvic  ligament.  A  strong  clamp  is  then  fastened  firmly 
upon  the  broad  ligament,  including  the  ovarian  artery.  Another 
is  placed  to  the  inner  side  of  the  first,  its  point  reaching  beyond 
the  round  ligament;  a  third  clamp  on  the  inner  side  of  the 
second  includes  all  the  tissues  attached  to  the  lateral  surface  of 
the  uterus,  its  points  projecting  beyond  the  free  inferior  border 
of  the  structures  separated  from  the  cervix  in  the  original  circu- 
lar incision  in  the  vaginal  vault,  the  operator's  forefinger  guarding 
the  points  of  the  clamp  as  it  is  closed  as  tightly  as  possible. 
The  half  of  the  uterus  thus  secured  is  cut  away  by  scissors, 
which  completely  sever  the  broad  ligament  and  connective  tissue 


248  Injuries  and   Diseases  of  the  Cervix 

on  the  inner  side  of  the  clamps.      The  other  half  of  the  uterus, 
hooked  down   by  a  finger  or  pulled  down  by  forceps,  is  turned 


Fig.  269. — Forceps 
for  catching  and  deliver- 
ing an  ovary. 


Fig.     270.^Catch     for-  Fig.     271. — Catch     for- 

ceps, open.  ceps,  closed. 


Fig.  272. — Teeth  of  the  catch  forceps.  Fig.  273. — Clamps  for  the  broad  liga- 

ment. 


upside  down  by  traction  on  the  fundus ;    the  tube  and  ovary  are 
brought   down  as  before,  the   clamps  are  applied  to  the  broad 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     249 

ligament,  and  the  second  half  of  the  uterus  is  removed  as  was  the 
first.  1  If  there  is  a  tendency  to  prolapse  of  the  intestines  through 
the  open  vault  of  the  vagina,  a  strip  of  gauze  is  lightly  packed  in 
the  opening,  being  pushed  beyond  the  cut  surfaces  of  the  liga- 
ments. The  field  of  operation  is  carefully  surveyed  for  a  minute 
or  two  to  detect  hemorrhage.  If  a  bleeding  point  is  observed, 
it  is  clamped  with  a  hemostat  or  a  short-bladed  forceps.  If 
packing  has  been  inserted  beyond  the  clamps,  it  is  removed.      A 


Fig.  274. — Uterus  delivered  from  the  pelvis  (Landau). 


fresh  strip  of  gauze  is  then  lightly  packed  into  the  opening,  ex- 
tending a  short  distance  beyond  the  clamps,  to  protect  the  intes- 
tines and  to  prevent  their  prolapse.  A  second  strip  of  gauze  is 
packed  into  the  vagina  between  the  clamps ;  a  third  is  placed 
gently  between  the  latter  and  the  vaginal  walls,  to  prevent  their 
being  bruised  or  wounded  by  the  shanks  of  the  instruments.    The 

^  The  operator  should  not  be  satisfied  with  the  common  custom  of  leaving  the 
tubes  and  ovaries  behind  in  a  vaginal  hysterectomy.  It  has  been  demonstrated  that 
they  may  contain  incipient  nodes  of  cancer. 


250  Injuries  and  Diseases  of  the  Cervix 

handles  of  the  forceps  projecting  from  the  vagina  are  enveloped 
in  a  sheet  of  gauze  and  are  further  supported  by  a  towel  folded 
around  them  and  pinned  to  the  abdominal  binder  in  the  shape 
of  a  sling.  Pryor's  forceps  with  detachable  handle  are  often 
most  convenient. 

The  greatest  care  must  be  exercised,  in  transporting  the 
patient  to  her  bed,  not  to  subject  the  clamps  to  any  violence  or 
traction,  which  might  pull  them  off  the  broad  ligaments.  When 
the   patient  is  placed  upon  her  back  in  bed,  a  folded  towel  is 


Fig.  275. — Uterus  with  appendages  pulled  out  of  the  vulva  (Landau). 


slung  around  each  thigh  just  above  the  knee,  both  ends  being 
pinned  to  the  bed  sheet  on  the  outer  side  of  the  legs,  thus  hold- 
ing them  apart  and  flexed.  The  vaginal  packing,  the  pelvic 
packing,  and  the  clamps  are  left  undisturbed  for  forty-eight 
hours,  the  patient  meanwhile  being  catheterized  every  eight  hours 
and  powdered  boracic  acid  being  dusted  thickly  upon  the  gauze 
enveloping  the  forceps  handles,  and  upon  the  external  genitalia. 
To  unfasten  and  remove  the  clamps,  the  gauze  around  their 
handles,  the  strip  in  the  vagina,  and  that  between  the  instruments 
and  the  vaginal  walls  are  first  removed.      The   catches  of  all  the 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     251 

clamps  are  then  unfastened  and  the  handles  gently  separated  a 
little.  Cautious  traction  is  made  first  upon  one  and  then  another 
until  it  is  discovered  which  comes  most  easily  first.  After  the 
removal  of  the  clamps,  the  gauze  strip  in  the  pelvis  is  extracted 
if  it  comes  away  easily ;  if  not,  it  is  left  another  day  or  two.  A 
fresh  packing  is  inserted  in  the  vagina  to,  but  not  through,  the 
vaginal  vault.  Landau's  ecarteurs  are  very  convenient  for  this 
purpose,  used  as  vaginal  retractors,  one  blade  on   the    anterior, 


Fig.  276. — Securing  the  uterine  artery  with  forceps  (Landau)-. 


the  other  upon  the  posterior  wall.  The  bowels  are  opened  on 
the  third  day.  The  vaginal  packing  is  renewed  daily.  Vaginal 
douching  may  be  ordered  after  the  first  week.  The  clamp  method 
is  preferable  to  ligatures  in  a  vaginal  hysterectomy.  The  latter  are 
much  more  difficult  to  apply  and  give  far  less  security  against 
hemorrhage.  They  are  likely  to  slip  even  if  well  applied,  and  there 
is  constant  danger  of  secondary  hemorrhage.  They  should  only 
be   used  in  case  of  prolapse  of  the  uterus  in  which  the  operation 


^5: 


Injuries  and  Diseases  of  the  Cervix 


is  conducted  outside  the  woman's  body  and  the  hgatures  are  ap- 
plied in  the  same  manner,  with  as  much  security  and  convenience 
as  in  an  abdominal  operation. 

Two  other  operations  for  cancer  of  the  cervix  merit  descrip- 
tion.     JVerdcrs  opcratioji  is  thus  described  by  himself : 

"  The  patient  having  been  anesthetized,  the  whole  vaginal 
portion  was  very  easily  removed  by  a  sharp  spoon  curet,  as  it 
was   completely  broken   down  by  the   disease.     The   remaining 


Fig.  277. — Securing  the  ovarian  artery  on  the  left  side  with  forceps  (Landau). 


bleeding  surface  was  seared  over  with  the  thermocautery.  The 
patient  was  then  prepared  for  laparotomy.  Both  ovaries  and 
tubes  were  found  adherent,  and  the  left  tube  distended  with  about 
an  ounce  of  creamy  pus.  After  the  ovarian  arteries  were  secured, 
the  bladder  was  separated  not  only  from  the  uterus,  but  also  from 
the  broad  ligaments  on  either  side  as  far  as  possible,  so  as  to  get 
the  uterus  out  of  the  way.  This  opened  up  both  broad  liga- 
ments, and  the  uterine  arteries  could  be  easily  traced  over  to  near 
the  pelvic  bones,  where  they  were   tied  without  difficulty.      An 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     253 

assistant  having  inserted  two  fingers  into  the  vagina  as  guides, 
the  dissection  between  bladder  and  vagina  was  then  carried  down 
to  within  about  an  inch  of  the  vulva.  The  sacro-uterine  liga- 
ments were  then  divided  with  scissors,  the  rectum  was  separated 
from  Douglas's  pouch,  and  with  two  fingers  the  dissection  ex- 
tended down  to  the  lower  half  of  the  vagina.  The  lateral  walls 
of  the  vagina  were  then  freed  from  their  attachments.  The 
uterus  and  vagina  were  now  only  held  by  the  base  of  the  broad 
ligaments,  which  were  very  firmly  bound  to  the  vaginal  fornices, 
the  separation  of  which  formed   the  only  really  difficult  part  of 


Fig.  278. — Anterior  wall  of  uterus  split  with  scissors  (Landau). 


the  operation.  This  having  been  accomplished  and  the  broad  liga- 
ments completely  divided,  the  finger  could  be  passed  all  around 
the  uterus  and  vagina,  and  at  no  place  had  the  vaginal  tube  been 
opened.  The  loss  of  blood  during  the  whole  operation  was  in- 
significant. The  uterus  and  vagina  were  then  pushed  down  into 
the  pelvic  outlet,  and  the  bladder,  with  its  peritoneal  flap  drawn 
across  the  pelvic  cavity,  stitched  over  the  rectum  to  the  posterior 
wall  of  the  pelvis,  thereby  completely  shutting  off  the  pelvis  from 
the  general  peritoneal  cavity,  and  covering  up  all  raw  surfaces 
with  peritoneum.  The  abdomen  was  closed  in  the  usual  manner. 
The  operation  having  been  done  in  the  Trendelenburg  posture, 


254 


Injuries  and   Diseases  of  the   Cervix 


the  patient  was  now  replaced  into  the  ordinary  hthotomy  posi- 
tion. The  uterus,  which  was  protruding  at  the  vulva,  was  seized 
with  volsella  forceps  and  drawn  completely  out  of  the  vulvar 
orifice  with  the  inverted  vagina.  With  the  finger  in  the  rectum 
and  the  sound  in  the  bladder  as  safeguards  against  injuring 
these  organs,  the  inverted  vagina  was  amputated  with  the  thermo- 
cautery. An  inspection  of  the  pelvis  showed  a  large  raw  cavity, 
lined  in  front  and  above  by  the  bladder,  behind  by  the  rectum, 
about  four  inches  of  which  was  completely  exposed,  and  below 


Fig.  279. — Half  of  the  uterus,  after  its  division,  delivered  from  the  vulva,  and  ready 
for  the  application  of  forceps  to  the  broad  ligament  (Landau). 


by  a  very  short  vagina.  The  cavity  was  lightly  packed  with 
gauze.  Duration  of  operation  two  hours.  Exarnination  of  the 
pelvis  on  the  tenth  day  showed  a  very  small  cavity  above  the 
remaining  vagina  covered  with  healthy  granulations,  in  which 
the  bladder  and  rectum  were  no  longer  recognizable.  The  ope- 
rative technic  I  found  much  easier  than  I  had  anticipated,  and  not 
more  difficult  than  a  total  abdominal  hysterectomy.  After  a  little 
experience  I  think  it  should  not  consume  more  time  than  the 
latter  operation.  I  would  suggest  the  use  of  rubber  gloves  for 
the  preliminary  curetment,  to  keep  the  hands  aseptic,  and  to  avoid 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     255 

contact  with  cancerous  tissue,  thereby  not  only  preventing  any 
danger  of  septic  contamination,  but  also  excluding  with  absolute 
certainty  the  possibility  of  inoculation.  "^ 

Byrne's  operation  is  thus  described  by  its  author: 
"A  diverging  volsella,  after  being  passed  well  into  the  cervical 
canal,  should  be  expanded  to  a  proper  degree  and  locked,  so  as 
to  afford  complete  control  of  the  uterus  during  the  entire  opera- 


Fig.  280. — Distending  and  holding  open  the  wound  with  hemostats  and  the  ecarteur 

(Landau). 


tion.  By  alternate  traction  and  upward  pressure  of  the  uterus, 
an  accurate  idea  may  be  obtained  as  to  the  proper  point  to  begin 
the  circular  incision,  so  as  to  avoid  injuring  the  bladder  or  open- 
ing into  the  cul-de-sac  of  Douglas.  As  to  the  latter,  however, 
should  it  be  found  that  the  disease  has  involved  the  retro-uterine 
tissues,  and  that  its  excision  or  destruction  by  the  cautery  can- 
not be  effected  without  opening  into  the  peritoneal   cavity,  there 

1  "Amer.  Jour,  of  Obstet. ,"  vol.  xxxvii,  No.  3,  1898. 


256 


Injuries  and  Diseases  of  the  Cervix 


need  be  no  hesitation  in  doing  so.  I  have  never  known  any 
harm  to  come  from  it  whether  it  was  done  accidentally  or  by 
design.  Should  it  be  evident  at  the  outset  that  the  operation,  in 
order  to  be  thorough,  must  include  a  portion  of  the  cul-de-sac, 
it  will  be  better  to  make  the  line  of  incision  anterior  to  this,  until 
the  cervix  has  been  removed,  and  leave  the  incision  of  the  retro- 
uterine  parts   by  the  cautery  knife  to  be    the   final   procedure. 


Fig.  281. — Inserting  a  gauze  strip  to  tampon  the  wound  (Landau). 


Under  these  circumstances  all  that  will  be  needed  will  be  an 
antiseptic  tampon  properly  applied.  In  proceeding  to  make  the 
circular  incision,  the  cautery  knife,  slightly  curved  and  cold, 
should  be  applied  close  up  to  the  vaginal  junction,  and  from  the 
moment  the  current  is  turned  on,  should  be  kept  in  contact  with 
the  parts  being  incised.  Before  removing  the  electrode  for  any 
purpose,  such  as  change  of  position  or  altering  the  curve  of  the 
knife,  the  current  should  first  be  stopped  and  the  instrument 
again  placed  into  position  while  cool  before  resuming  the  incision. 
In  other  words,  if  the  knife,  though  heated  only  to  a  dull  red, 
be  applied  to  parts  at  all  vascular,  hemorrhage  more  or  less  will 
-certainly  follow  ;   whereas,  the  cool  platinum  blade  being  already 


Treatment  of  Carcinoma  of  the  Cervix  Uteri     257 

in  contact  with  moisture  as  the  current  is  being  transformed  into 
heat,  vessels  are  shrunken  or  closed  even  before  they  are 
severed.  This  is  a  very  important  point  and  should  never  be 
lost  sight  of  in  all  cautery  operations.  The  circular  incision 
having  been  made  to  the  depth,  sa\\  of  a  quarter  of  an  inch,  it 
will  now  be  observed  that  by  increased  traction  the  uterus  may 
be  drawn  much  farther  downward,  and  by  directing  the  knife 
upward  and  inward  the  amputation  may  be  carried  to  any  desired 
extent.  In  cases  calling  for  amputation  above  the  os  internum, 
it  will  be  better  to  excise  and  remove  the  cervix  first ;  then,  by 
dilating  the  upper  canal  sufficienth^  to  admit  the  diverging 
volsella,  once  more  proceed  as  in  the  first  instance,  taking  care, 
however,  to  keep  within  bounds.  It  will  be  found  that  the 
cupped  stump  can  now  be  drawn  down  and  made  to  project  as  a 
more  or  less  convex  body.  In  all  cases  the  dome-shaped 
electrode  should  be  passed  over  the  entire  cavity  repeatedly  so 
as  to  render  the  cauterization  still  more  complete.  It  is  im- 
portant to  add  that,  in  carrying  the  knife  toward  the  sides  of  the 
cervix,  circular  and  other  arterial  branches  are  likely  to  be  en- 
countered, and  hence,  in  this  locality  particularly,  a  high  degree 
of  heat  in  the  platinum  blade  is  to  be  carefully  avoided.  As  an 
additional  security  against  hemorrhage,  the  convexity  of  the  knife 
should  be  pressed  against  the  external  surface  of  each  particular 
section  cut,  so  as  to  close  the  vessels  more  effectually.  It  is  well 
to  state  that  the  metallic  parts  of  the  electrode  for  the  distance  of 
about  two  inches  should  be  covered  with  a  strip  of  thin  flannel, 
so  that  the  vagina  may  be  protected  from  injury  through  the 
reflected  heat. 

"  I  stated  that  in  40  out  of  6t,  cases  of  cancer  of  the  portio 
vaginalis  (23  having  strayed  away)  periods  of  exemption  from 
relapse  were  obtained  ranging  from  two  to  twenty-two  years, 
being  an  average  of  over  nine  years  for  each  ;  and  of  50  out  of 
81  cases  involving  the  entire  cervix  (31  being  lost  sight  of),  10 
had  an  exemption  from  recurrence  for  over  two  years,  t  i  over 
three  years,  6  over  four  years,  8  over  five  years,  6  over  seven 
years,  2  over  eleven  years,  i  over  thirteen  years,  and  i  over 
seventeen  years.  Nor  is  this  all,  ibr  the  table  would  now  bear 
important  reconstruction — no  less  than  6  of  these  cases,  and 
probably  many  more,  having  until  now  enjoyed  a  complete 
immunity.  Moreover,  one  patient  operated  on  in  1875,  and  a 
most  unpromising  case,  too,  and  who  could  not  be  found  at  the 
time  of  my  report,  has  since  been  discovered  by  Dr.  Homer  L. 
Bartlet,  of  Flatbush,  with  whom  I  saw  her,  and  who  was  present 
at  the  operation.  Two  months  ago,  or  nearly  twenty-one  years 
after  the  operation,  she  was  in  perfect  health." 
17 


258  Injuries  and   Diseases  of  the  Cervix 

The  Prognosis  of  the  Operative  Treatment  of  Cancer  of  the  Cervix 
Uteri. — A  recurrence  of  the  cancer  after  its  removal  by  hyster- 
ectomy has  hitherto  been  at  least  the  rule.  The  growth  recurs 
in  one  of  four  ways  :  (i)  In  or  about  the  scar  of  the  vaginal 
wound  ;  (2)  in  the  lymphatic  glands  ;  (3)  by  metastasis  in  dis- 
tant organs  ;  (4)  in  the  neighborhood  of  the  field  of  operation 
by  an  implantation  metastasis.  ^ 

Local  or  wound  recurrence  is  almost  the  invariable  rule.  A 
number  of  observers  have  found  in  the  microscopical  study  of 
uteri  removed  for  cancer  of  the  cervix  an  extension  of  cancer 
cells  laterally  or  posteriorly  in  fine  ray-like  growths,  only  appar- 
ent under  the  microscope.  Outlying  nests  of  cancer  cells  may 
be  discovered  with  apparently  healthy  tissue  intervening  be- 
tween them  and  the  parent  growth.  The  operator,  therefore,  often 
leaves  cancerous  tissue  behind,  although  he  makes  his  incisions 
in  structures  apparently  healthy  and  provides  a  wdde  margin  be- 
tween his  incisions  and  the  cancer.  The  large  majority  of 
specimens  examined  show  this  result.  ^  The  discouraging  pro- 
portion of  recurrences  after  the  radical  operation  for  cancer 
of  the  cervix  is  therefore  not  strange.  A  recurrence  of  can- 
cer in  the  lymphatic  glands  is  rare.  The  lymphatic  ducts  of 
the  upper  vagina  and  of  the  cervix  run  along  the  bases  of  the 
broad  ligaments  and  then  upward  to  the  iliac  glands,  situated  just 
below  the  iliopectineal  line,  in  front  of  the  sacro-iliac  synchon- 
drosis, and  in  the  fork  of  the  great  iliac  arteries,  where  they  divide 
into  the  internal  and  external  branches.  The  ducts  of  the  uterine 
fundus  follow  the  ovarian  arteries  in  the  upper  edges  of  the  broad 
ligament  and  then  run  upward  to  the  lumbar  retroperitoneal 
glands  in  front  of  the  aorta.  A  subordinate  system  of  small 
ducts  runs  from  the  uterine  cornua  along  the  round  ligaments  to 
the  glands  in  the  groins.  The  iliac  lymphatic  glands,  therefore, 
are  the  seat  of  lymphatic  involvement  in  cancers  of  the  cervix, 
but  they  are  not  often  affected.  In  two-thirds  or  more  of  the 
fatal  cases  the  iliac  glands  are  found  free  from  disease  at  the 
postmortem  examination. 

A  recurrence  of  cancer  of  the  cervix  by  metastasis  in  a  dis- 
tant organ  is  quite  exceptional.  In  202  cases  Winter  found  met- 
astasis in  9 — 2.5  per  cent.  That  implantation  metastasis  is  possi- 
ble is  shown  by  experiments  upon  animals  and  human  beings  and 
by  clinical  observation.  The  possibility  must  be  borne  in  mind 
and  guarded  against  in  the  operative  technic,  but  recurrence  of  a 
cervical  cancer  in  this  manner  is  the  rarest  of  all.  There  is  a 
wide  divergence  in  the  actual  results  secured  by  the  radical  treat- 
ment of   cancer  of  the   cervix.      Byrne's   statistics  have  already 

^  Winter,  op.  cit.  2  Frommel,  in  Veil's  "  Handbuch,"  vol.  3  1. 


Prognosis  of  Carcinoma  of  the   Cervix  Uteri    259 

been  cited.  Richelot  claims  10  per  cent,  of  cures  ;  Winter,  in 
the  operations  of  the  Berlin  Frauenklinik  prior  to  1892,  30  per 
cent.;  Olshausen,  18  per  cent.;  Schauta,  3 1  percent.;  Kalten- 
bach,  14  per  cent;  Fritsch,  36  per  cent.;  Leopold,  53  per  cent. 
Jacobs,  in  82  vaginal  hysterectomies,  saw  a  recurrence  in  every 
one  within  a  }'ear,  and  all  the  patients  are  now  dead.  Baldy  and 
Robb  claim  that  less  than  5  per  cent,  of  cancers  of  the  cervix 
are  permanently  cured  by  the  radical  operation.  In  Kelly's 
clinic,  of  75  cancers  of  the  cervix,  only  5  per  cent,  are  perma- 
nently cured.  Noble,  in  23  cases  of  hysterectomy  for  cancer  of 
the  cervix,  is  able  to  report  3  without  recurrence  after  five  years.  ^ 
The  author  has  had  44  vaginal  and  1 1  combined  hysterectomies 
for  cancer  of  the  cervix,  with  4  deaths  from  the  operations. 
Four  of  these  patients  are  known  to  be  alive  after  five  years. 
All  the  rest  are  dead  from  recurrent  growths,  too  recently  operated 
upon  to  be  regarded  as  cured,  or  unheard  from.  The  prognosis 
depends  largely  upon  the  stage  of  the  cancer  at  the  time  of  ope- 
ration. There  is  a  period  when  all  cancers  of  the  cervix  are  prob- 
ably curable,  but  unfortunately  this  period  is  usually  past  when 
the  operator  first  sees  the  patient.  The  more  ignorant  the 
patient,  the  less  likely  she  is  to  apply  for  medical  aid  in  time.  In 
the  author's  fifteen  years'  gynecological  service  in  the  Philadel- 
phia Hospital  there  have  never  been  less  than  3  patients  in  the 
cancer  ward;  often  many  more.  Of  the  75  or  more  cases  of 
cancer  of  the  cervix  in  that  institution  under  the  author's  care, 
there  has  been  but  one  operable  case,  and  that  woman  positively 
refused  operation. 

Recurrence  after  the  removal  of  a  cervical  cancer  is  usually 
observed  within  the  first  three  years  ;  it  is  uncommon  between 
the  third  and  fifth  year,  and  is  very  rare  after  five  years.  It  has, 
however,  been  observed  at  the  end  of  twelve  years  (Olshausen). 
Nodes  are  felt  in  the  vaginal  scar,  or  may  be  made  out  by  a 
rectal  examination  in  the  bases  of  the  remnants  of  the  broad  liga- 
ments. The  recurrence  may  take  the  form  of  cancerous  infiltra- 
tion of  the  pelvic  connective  tissue,  with  a  firm  mass  extending 
laterally  and  posteriorly  like  a  pelvic  inflammatory  exudate.  If 
the  iliac  lymphatic  glands  are  involved,  they  may  be  felt  by  deep 
abdominal  palpation  in  an  examination  under  anesthesia,  as 
hard,  movable  nodules.  A  serosanguinolent  vaginal  discharge 
appears,  and  the  later  ulcerative  stages  of  the  disease  have  many 
of  the  same  clinical  features  that  are  presented  by  an  advanced 
inoperable  cervical  cancer. 

Granulation  tissue  around  a  silk  ligature  or  the  inclusion  of 

^  "  Phila.  Med.  Jour.,"  Nov.  9,  1901.  I  am  indebted  to  Dr.  Noble's  article  for 
the  foregoing  statistics.  ' 


26o  Injuries  and   Diseases  of  the  Cervix 

one  end  of  a  Fallopian  tube  and  pouting  of  its  mucous  mem- 
brane may  suggest  a  recurrence  of  cancer,  but  there  is  no  exu- 
berant growth,  no  friability  of  the  tissue,  and  no  infiltration 
around  the  suspected  area.  A  microscopical  study  of  a  fragment 
of  tissue  removed  for  the  purpose  is  conclusive. 

The  Palliative  Treatment  of  Cervical  Cancer. — If  the  case  is  in- 
operable the  patient  may  often  be  made  comfortable  for  some 
months  at  least,  and  her  life  may  be  prolonged  by  removing  or  de- 
stroying as  much  of  the  cancer  as  possible  and  by  the  ,r-ray  treat- 
ment. The  exuberant  growth  is  scraped  away  with  a  serrated 
curet ;  portions  of  it  too  solid  to  be  removed  by  the  curet  may  be 
cut  off  with  scissors.  The  hemorrhage  may  appear  formidable  at 
first,  but  it  grows  less  as  the  redundant  tissue  is  removed.  There 
is  always  danger  of  opening  Douglas's  pouch  or  the  bladder  in 
this  operation.  The  former  accident  has  no  serious  consequences 
and  need  give  the  operator  no  concern.  The  latter,  however, 
should  be  carefully  avoided,  as  the  vesicovaginal  fistula  makes 
the  patient  more  miserable  than  she  was  before  the  operation. 
The  raw  surface  remaining  usually  in  the  shape  of  a  deep  pit  in 
the  vaginal  vault  is  thoroughly  charred  with  a  Paquelin  cautery 
or  an  electrocautery  point,  the  vaginal  walls  being  protected 
by  four  retractors  or  by  a  short  cylindrical  speculum  of  wood 
or  hard  rubber.  The  vagina  is  washed  out  with  a  douche 
of  sterile  water  and  is  well  dried.  The  walls  are  coated 
with  an  ointment  of  one  part  sodium  bicarbonate  and  three 
parts  ung.  petrolei.  A  tampon  of  cotton  large  enough  to 
fill  the  cavity  of  the  cancer  is  moistened,  but  not,  soaked, 
with  a  50  per  cent,  solution  of  chlorid  of  zinc  and  is  placed 
in  the  cavity  left  by  the  curetment.  A  string  is  tied  to  it 
to  facilitate  its  removal.  The  vagina  is  packed  with  a  strip  of 
gauze  smeared  with  the  bicarbonate  of  sodium  ointment,  which 
will  neutralize  the  zinc  solution  and  prevent  an  ulceration  of  the 
vagina  which  might  otherwise  be  serious.  The  gauze  is  removed 
at  the  end  of  forty-eight  hours.  The  zinc  chlorid  tampon  is 
allowed  to  remain  eight  or  ten  days,  when  it  maybe  removed  by 
gentle  traction  on  the  string,  often  bringing  with  it  a  large  slough 
of  cervical  tissue.  The  improvement  in  the  patient's  condition  is 
often  astonishing.  The  cachexia  disappears  ;  she  regains  color, 
weight,  and  strength ;  the  vaginal  discharge  ceases.  She  may 
obtain  a  respite  from  her  former  symptoms  for  months  and  even 
years.  The  author  has  seen  a  patient  remain  comfortable  after 
this  treatment  for  three  years.  Usually,  however,  the  symptoms 
of  ulceration  and  sloughing  return  in  about  six  months.  Deo- 
dorant douches  of  permanganate  of  potassium  and  of  creolin 
must  then  be  ordered.      Pelvic  pain  of  an  excruciating  character 


Roentg-en  Rays  in  Carcinoma  of  Cervix  Uteri     261 

may  appear.  The  patient  should  be  encouraged  to  become  an 
opium  eater  until  she  obtains  comparative  comfort. 

After  a  radical  operation  periodic  examinations  should  be 
made.  If  there  is  a  recurrence,  the  cancerous  nodules  accessible 
in  a  vaginal  examination  ma}'  be  cauterized  by  local  applications 
of  zinc  chlorid,  but  the  best  treatment  is  the  application  of  the 
Roentgen  ray. 

The  Roentgen  and  the  Finsen  Rays  for  Inoperable  and  Recurrent 
Cancers  of  the  Cervix. — It  is  too  early  to  decide  what  the  ultimate 
results  of  the  x-ray  treatment  of  cancer  of  the  cervix  will  be.  A 
cure  can  hardly  be  expected,  but  there  is  no  doubt  of  the  enormous 
symptomatic  relief  afforded.  Hemorrhage  often  ceases,  the  dis- 
charge diminishes  or  disappears,  pain  is  relieved,  and  a  patient 
practically  bedridden  may  be  restored  to  an  active  life. 

In  the  clinic  which  has  been  established  for  the  treatment  of 
these  cases  in  the  Howard  Hospital,  the  patient  is  placed  on  a 
gynecological  table  in  the  dorsal  position.  The  thighs,  vulva, 
and  mons  veneris  are  protected  with  zinc  foil.  A  large  cali- 
ber, short  Ferguson's  cylindrical  speculum  is  inserted  in  the 
vagina,  exposing  the  cancerous  area.  The  ,f-ray  tube  is  held 
some  four  or  five  inches  away  from  the  vulva  and  the  depth  of 
the  canal  is  exposed  to  the  rays  for  eight  to  ten  minutes.  The 
treatment  is  applied  four  to  six  times  a  week. 

Charles  Lester  Leonard,  of  Philadelphia,  uses  two  Collin's 
specula  opened  anteroposteriorly  and  laterally,  one  fitting  inside 
the  other.  He  incloses  the  Crookes  tube  in  a  metal-lined  box 
with  a  fenestra,  so  that  the  rays  are  concentrated  on  the  vagina. 
By  this  plan  protection  of  the  external  parts  is  unnecessary. 

Another  kind  of  box  supported  by  twine  is  hung  over  the 
hypogastrium  for  cases  of  pelvic  infiltration  not  reached  by  the 
vaginal  application.  Pennington  ^  has  designed  special  tube  shields 
and  specula  of  metal  to  inclose  the  Crookes  tube  and  to  insert  in 
the  vagina  or  rectum,  which  should  often  be  a  great  convenience. 

The  Finsen  actinic  or  ultra-violet  ray  has  such  a  feeble  power 
of  penetration  that  it  will  probably  prove  of  subordinate  value 
in  the  treatment  of  cervical  cancer.  The  author  has  no  personal 
experience  with  it.  The  high-frequency  current  emitting  the 
violet  ray  in  its  sparks  and  possessing  other  therapeutic  powers 
of  its  own  is  likely  to  prove  more  valuable. 

Hydatidiform  sarcoma  of  the  cervical  endometrium  is  a 
name  given  to  a  peculiar  and  rare  growth  of  the  cervical  mucous 
membrane,  first  described  by  Weber  ^  in  1 86^.  From  a  broad 
pedicle  a  tumor  grows  out  into  the  cervical  canal  and  soon  pro- 

1  "Phila.  Med.  Jour.,"  Dec.  13,  1902. 

2  "  Virchow's  Archiv,"  Bd.  xxxix,  p.  216. 


262 


Injuries  and  Diseases  of  the  Cervix 


trudes  from  the  os  into  the  vagina.  The  portion  projecting  into 
the  vagina  assumes  the  form  of  a  bunch  of  grapes,  varying  in 
size,  yellow,  brown,  or  bluish-black  in  color.  In  addition  to  the 
spindle,  round,  and  giant  cells  of  sarcoma,  the  tumor  may  con- 
tain striped  muscle-fibers  and  hyaline  cartilage.  It  is  not  yet 
known  from  what  part  of  the  endometrium  the  growth  originally 
springs.  The  peculiar  grape-like  form  of  the  tumor  in  the 
vagina  is   due  to  obstructed  circulation  and  a  very  rich    blood- 


Fig.  282. — Hydatidiform  sarcoma  of  the  cervix  :  Z,  Dotted  line  showing  the  in- 
cision of  the  operation  ;  a,  isolated  grape-like  excrescence  ;  b,  numbers  of  single 
"  berries"  grown  together;  c,  delicate  membrane,  epithelial  in  structure,  stretched  in 
part  over  the  growth  (Pernice). 


supply,  the  vesicles  containing  serum,  jelly-like  mucus,  or  myx- 
omatoid  material  and  blood.  This  form  of  sarcoma  occurs  at 
any  time  from  infancy  to  old  age.  It  has  most  frequently  been 
observed  in  the  very  young  or  the  middle  aged. 

The  symptoms  are  leukorrhea,  metrorrhagia,  a  foul  discharge, 
dysuria  from  pressure  on  the  bladder,  dyspareunia  from  the 
obstruction  of  the  vagina  and  possibly  the  protrusion  of  the 
tumor  from  the  vulva. 

The  treatment  is  hysterectomy. 


Hydatidiform  Sarcoma  of  Cervical  Endometrium   263 

The  prognosis,  judging  from  the  reported  cases,  is  not  good. 
They  have  all  died.  Possibly  an  earlier  diagnosis  would  have 
saved  them,  but  tiie  symptoms  are  not  sufficiently  troublesome 
at  first  to  compel  a  patient  to  seek  medical  advice,  and  the 
appearance  of  the  growth  at  first  would  probably  be  so  much 
like  a  mucous  polyp  that  the  differential  diagnosis  might  be  diffi- 
cult. The  recurrence  of  a  growth  regarded  as  a  mucous  polyp 
should  arouse  suspicion  of  sarcoma,  and  every  polypoid  tumor 
removed  from  the  cervix  should  be  examined  microscopically. 


PART  VI. 
DISPLACEMENTS  AND  DISEASES  OF    THE   UTERUS. 

The  Hterus  in  its  anatomical  position  is  the  central  organ  of  the 
sexual  system  in  women.  It  may  be  called  the  most  important 
organ  also  in  view  of  its  chief  function  as  the  receptacle  of  the 
impregnated  ovum  and  as  the  main  source  of  the  menstrual  dis- 
charge. 

Form  and  Divisions. — In  shape  the  uterus  is  pyriform,  flat- 
tened anteroposteriorly.  It  is  divided  into  the  cervix  or  neck,  the 
corpus  or  body,  and  the  fundus.  It  is  necessary,  moreover,  to 
consider  separately  the  periinetritiin,  or  the  peritoneal  invest- 
ment ;  the  parametrium,  or  connective  tissue  surrounding  the 
supravaginal  portion  of  the  cervix  and  the  lower  uterine  segment ; 
the  myo77ietr'ium,  or  muscular  body  of  the  organ  ;  and  the  endo- 
metrium, or  the  mucous  lining  of  the  uterine  cavity. 

The  cervix  uteri  has  been  described.  The  corpus  uteri  extends 
from  the  isthmus  or  the  internal  os  to  the  level  of  the  tubal  inser- 
tions; it  occupies  about  two-thirds  the  length  of  the  uterus. 
The  fundus  uteri  projects  above  the  insertion  of  the  tubes.  It  is 
domes-haped.  Within  the  body  of  the  uterus  is  its  cavity.  In 
longitudinal  transverse  section  the  cavity  is  triangular  in  shape, 
with  the  base  of  the  figure  above  and  the  apex  below.  The 
lateral  and  superior  borders  of  this  figure  curve  inward  toward 
the  cavity  in  a  nulliparous  woman. 

The  perimetrium  invests  the  fundus  uteri,  the  anterior  and  pos- 
terior surfaces  of  the  corpus,  and  by  lateral  extensions  forms  the 
broad  ligaments.  The  peritoneum  is  tightly  adherent  to  the  uterus 
except  on  the  anterior  and  posterior  surfaces  of  the  lower  uterine 
segment  or  isthmus  uteri,  and  on  the  posterior  surface  of  the 
cervix,  where  it  is  separated  from  the  myometrium  by  cellular 
tissue  that  admits  of  a  peritoneal  flap  being  stripped  or  dissected 
off.  The  dividing  line  between  the  tightly  adherent  and  the  sep- 
arable perimetrium  is  not  sharply  defined,  but  one  zone  gradually 
passes  into  the  other.  On  the  anterior  surface  the  loose  attach- 
ment extends  higher  than  on  the  posterior. 

The  perimetrium  passes  anteriorly  into  the  reduplication  of 
peritoneum  forming  the  vesico-uterine  pouch  and  posteriorly  into 
the  reduplication  forming  the  recto-uterine  or  Douglas's  pouch. 

264 


The  Uterus 


265 


The  parainctrijim  is  the  connective  and  elastic  tissue  in  the 
bases  of  the  broad  Hgaments  and  under  the  anterior  and  pos- 
terior redupHcations  of  the  peritoneum.      It  is  that  portion  of  the 


Fig.  283. — Median  transverse  section  of  uterus  and  vagina,  posterior  view  ;  left 
tube  and  ovary  in  section  ;  posterior  layer  of  left  broad  ligament  removed  :  i ,  Uterine 
cavity  ;  2,  ovarian  ligament ;  3,  intramural  portion  of  left  tube  ;  4,  right  tube  and 
tubal  branch  of  uterine  artery ;  5,  round  ligament ;  6,  Farre's  line  on  the  ovary  ;  7, 
tubal  isthmus  ;  8,  accessory  ostium  of  tube  ;  9,  parenchymatous  zone  of  ovary ;  10, 
epoophoron  (parovarium);  li,  vascular  zone  of  ovary;  12,  infundibulum  and  ab- 
dominal ostium  of  tube  ;  13,  Graafian  follicle  ;  14,  bulbus  ovarii  and  pampiniform 
plexus;  15,  corpus  luteum  ;  16,  cyst  of  epoophoron  (parovarium),  epoophoron  and 
its  duct;  17,  hydatid  of  Morgagni  (vesicular  appendix)  ;  18,  abdominal  ostium  of 
tube  ;  19,  fimbria;  of  tube  ;  20,  a  bilocular  vesicular  appendix  ;  21,  ovarian  fimbria  ; 
22,  broad  ligament ;  23,  ovarian  artery  with  its  veins  ;  24,  vesicovaginal  vessels  ; 
25,  secdon  of  left  ovary  ;  26,  internal  os  uteri  ;  27,  ovarian  artery  and  veins  ;  28, 
left  ureter;  29,  right  ureter  ;  30,  uterine  artery  ;  31,  uterine  blood-vessels  ;  32,  uter- 
ine vein  ;  33,  cervical  canal ;  34,  cervicovaginal  branch  of  uterine  artery  ;  35, 
vaginal  wall  ;  36,  vesicovaginal  plexus  ;  37,  levator  ani  muscle  ;  38,  vesicovaginal 
artery  and  vein  ;  39,  muscle  of  the  urogenital  trigonum  ;  40,  external  os  uteri  ;  41, 
bulbus  vestibuli ;  42,  anterior  vaginal  wall  ;  43,  external  urinary  meatus  ;  44,  anterior 
extremity  of  labium  minus  ;   45,  interlabial  space  (Waldeyer). 


pelvic  connective  tissue  surrounding  the  cervix  and  lower  uterine 
segment. 

The    myometrium  is    unstriped  muscular  tissue  arranged    in 
three  layers :  a  thick  median  layer,  the  fibers  having  a  direction 


2  66     Displacements  and  Diseases  of  the  Uterus 

mainly  circular;  and  an  outer  and  inner  layer  of  fibers,  mainly 
longitudinal  in  direction.  The  muscular  tissue  of  the  uterus  is 
continuous  with  that  of  the  tubes,  the  vagina,  the  broad,  round, 
uterosacral,  and  ovarian  ligaments. 

TJic  cndovictrhini  is  i  to  2  millimeters  thick.  There  is  no 
submucosa;  the  mucous  membrane  is  in  direct  contact  with  the 
m^-ometrium.  The  membrane  is  smooth ;  there  are  no  folds  or 
projections.      There  are  numerous  tubular  glands,   mostly  with 

a  be  d 


Fig.  284. — Transverse  section  of  corpus  uteri :  a,  Myometrium  ;  b,  vascular  layer 
of  the  myometrium  ;  c,  supravascular  layer  of  myometrium  ;  d,  serous  coat ;  <?,  begin- 
ning of  the  broad  ligament ;    f,  uterine  cavity  ;  g,  endometrium  (Waldeyer). 


Fig.  285. — Transverse  section  of  fundus  uteri  :  a.  Uterine  cavity  ;    b,  uterine  ostium 
of  tube  ;  c,  uterine  portion  of  tube  (Waldeyer). 


a  single  canal,  sometimes  branched,  running  a  spiral  course  and 
opening  upon  the  surface  of  the  membrane  in  funnel-shaped 
orifices  visible  to  the  naked  eye.  The  mucosa  proper  or  inter- 
glandular  structure  consists  of  a  network  of  fine  connective- 
tissue  fibers  with  flat,  star-  and  spindle-shaped  cells  at  their  points 
of  junction,  and  in  their  meshes  round-cells  of  moderate  size. 
The  secretion  of  the  uterine  glands  is  scanty,  affording  nor- 
mally nothing    more    than  a    moisture    in    the    uterine  cavity. 


PLATE  10. 


Uterus  and  appendages  of  a  virgin,  sixteen  years  old,  seen  from  above  :  a.  Me- 
dian umbilical  ligament;  /',  lateral  umbilical  ligament;  <-,  inferior  epigastric  vessels; 
(/,  transverse  vesical  fold;  c,  round  ligament  of  uterus;  /',  tubal  isthmus,  pampini- 
form plexus,  ovarian  ligament;  "■,  uterine  pole  of  the  ovary;  h,  origin  of  internal 
iliac  artery;  i,  ovarian  vein;  J,  ureter;  k,  right  ovarian  artery;  /,  suspensory  liga- 
ment of  the  ovary  (infundibulopelvic  ligament);  w,  colon;  ii,  inferior  mesenteric 
vessels  and  lymph-glands;  o,  vessels  of  fourth  lumbar  vertebra;  sympathetic  nerve- 
trunk  and  ganglion  (Waldeyerj. 


Blood-vessels  of  the  Uterus 


267 


The  epithelium  of  the  endometrium  is  cyUndrical  and  ciliated. 
The  cilia  lash  toward  the  os  uteri.  The  nuclei  of  the  cells  are 
usually  in  their  middle.      The  protoplasm  stains  well. 

The  blood-vessels  of  the  uterus  are  the  ovarian  and  uterine 
arteries  with  their  accompanying  veins.  The  latter  is  the 
main  and  almost  the  sole  source  of  arterial  blood  to  the 
uterus,  but  the  former  must  be  taken  into  account  because  of 
its  wide  anastomosis  with  the  ovarian  branch  of  the  uterine 
artery.      The  artery  of  the  round  ligament,  a  branch  of  the  epi- 


Fig.  286. — The  arteries  of  the  uterus  and  ovaries:  O.A.,  Ovarian  artery;  i>, 
artery  of  the  round  ligament  ;  d\  branch  to  the  tube  ;  (",  c,  c,  branches  to  the  ovary  ; 
d,  continuation  of  main  trunk  ;  e,  branch  to  the  cornu  ;  U.A.,  uterine  artery  ;  e,  main 
trunk  ;  /j  bifurcation  ;  g,  vaginal  branches  ;  h,  vaginal  branch  from  the  cervical 
artery  (Hyrtl). 


gastric,  is  an  insignificant   vessel  anastomosing  with  the   uterine 
artery. 

The  uterine  artery  arises  from  the  anterior  main  branch  of 
the  internal  iliac  artery,  runs  downward  along  the  outer  side  of 
the  ureter,  and  then  inward,  crossing  in  front  of  the  latter  in  the 
base  of  the  broad  ligament,  at  the  level  of  the  supravaginal  portion 
of  the  cervix  and  about  2  centimeters  from  the  lateral  border 
of  the  uterus.  At  this  point  the  main  branch  of  the  uterine 
artery  is  given  off — the  cervicovaginal  artery.  The  course  of  the 
artery  is  then  inward  to  the   supravaginal   portion  of  the  cervix, 


268      Displacements  and   Diseases  of  the  Uterus 

upward  by  a  turn  at  right  angles  to  its  former  course  along  the 
lateral  border  of  the  uterus,  to  which  numerous  small  branches 
are  given  off  until  it  reaches  the  level  of  the  ovarian  ligament, 
where  it  gives  off  the  tubal  branch,  branches  to  the  fundus  uteri, 
and  the  main  branch,  the  ovarian,  which  becomes  continuous 
with  the  ovarian  artery.  In  nulliparous  women  the  uterine  artery 
runs  a  comparatively  straight  course  along  the  lateral  border  of 
the  uterus  and  almost  a  centimeter  removed  from  it.  In  women 
who  have  borne  children  the  course  is  much  more  tortuous  and 
the  artery  lies  so  close  to  the  myometrium  as  to  be  separated 
from  it  with  difficulty. 

The  ovarian  artery  arises  from  the  aorta,  runs  downward  and 
inward  in  the  upper  portion  of  the  broad  ligament,  anastomosing 
with  the  ovarian  branch  of  the  uterine  artery.  The  two  are 
practically  continuous.  It  is  impossible  to  say  where  one  leaves 
off  and  the  other  begins.  The  veins  of  the  uterus  are  thin- 
walled  sinuses  in  the  myometrium,  emptying  into  the  venous 
plexuses  on  the  lateral  borders  of  the  uterus.  Thence  the  venous 
blood  flows  downward  to  mingle  with  that  of  the  uterovaginal 
plexuses.  At  the  level  of  the  internal  os  the  blood  from  these 
plexuses  is  carried  off  by  two  uterine  veins  accompanying  the 
uterine  artery  and  emptying  into  the  internal  iliac  vein. 

TJie  lymphatics  of  the  litems  have  their  origin  in  three 
sources — the  endometrium,  the  myometrium,  and  the  perime- 
trium. Two  or  three  ducts  run  from  the  lateral  border  of  the 
uterus  to  the  hypogastric  or  iliac  glands  into  which  the  lymphatic 
ducts  of  the  cervix  empty  and  which  have  already  been  noticed. 
Other  ducts  from  the  fundus  and  the  cornua  of  the  uterus 
accompany  the  ovarian  artery  to  the  lumbar  glands  in  front  of 
the  aorta  at  the  level  of  the  lower  end  of  the  kidney.  A  few 
small  branches  accompany  the  round  ligaments  and  terminate  in 
the  inguinal  glands. 

The  Nerves  of  the  Uterus. — Cerebrospinal  branches  from  the 
second,  third,  and  fourth  sacral  nerves  supply  the  uterus  from 
the  central  nervous  system.  The  greater  and  more  important 
nerve-supply  is  derived  from  the  sympathetic  system. 

From  the  interiliac  plexus  large  branches  run  along  the  rec- 
tum and  the  uterosacral  ligaments  to  the  cervical  ganglion,  sit- 
uated behind  the  point  where  the  uterine  artery  crosses  the 
ureter.  Other  branches  are  derived  from  the  hypogastric  plexus 
and  from  two  ganglions  situated  at  the  entrance  of  the  ureter 
into  the  bladder  and  between  the  former  and  the  cervix. 

The  Ligaments  and  Supports  of  the  Uterus. — The  uterus  is 
slung  between  the  broad  ligaments  laterally,  the  round  ligaments 
anteriorly,    and    the    uterosacral    ligaments    posteriorly.       It    is 


PLATE  It. 


Median  section  tinougii  the  pelvis  of  a  multipara;  the  peritoneum  is  represented  by  a 
black  line:  I,  Left  common  iliac  vein;  2,  right  common  iliac  artery;  3,  right  common  iliac 
artery  and  vein;  4,  promontory;  5,  obturator  nerve;  6,  suspensory  ligament  of  ovary;  7, 
Fallopian  tube;  8,  umbilical  artery;  9,  right  external  iliac  vein;  lo,  right  external  iliac  ar- 
tery; II,  right  ureter;  12,  right  hypogastric  artery  and  vein;  13,  uterine  artery ;  14,  ovary; 
15,  uterine  cavity;  16,  Douglas's  pouch;  17,  rectum;  18,  tirst  coccygeal  vertebra;  19, 
vaginal  vault  and  posterior  lip  of  cervix;  20,  vaginal  vault  and  anterior  lip  of  cervix;  21, 
longitudinal  muscular  coat;  22,  anococcygeal  ligament;  23,  circular  muscular  coat;  24, 
rectus  muscle  of  abdomen;  25,  superior  vesical  artery  ;  26,  cervical  canal ;  27,  vesico-uterine 
pouch  and  bladder;  28,  cavity  of  the  symphysis;  29,  urethra;  30,  urethrovaginal  septum; 
31,  urogenital  trigonum  muscle  ;  32,  clitoris  and  dorsal  vein  of  the  clitoris ;  ^^,  vagina  and  bul- 
bocavernosus  muscle;  34,  labium  majus;  35,  labium  minus;  36,  perineum;  37,  perineal  por- 
tion of  the  rectum  and  external  sphincter  muscle;  38,  round  ligament  of  uterus  (^Waldeyer). 


The  Mobility  and  Position  of  the  Uterus       269 

further  supported  b}-  the  posterior  wall  of  the  vagina,  and  b\'  the 
parametrium,  especially  by  the  well-developed  elastic,  connec- 
tive tissue  and  muscle-fibers  accompanying  the  uterine  arteries, 
which,  by  their  specialized  development,  deserve  the  name  of 
ligaments.  They  are  called  the  transverse  or  cardinal  ligaments 
of  the  cervix.  In  the  erect  posture  the  bladder  affords  the  uterus 
considerable  support  in  a  moderately  distended  condition,  and 
the  intra-abdominal  pressure  with  the  weight  of  the  abdominal 
contents  upon  the  posterior  uterine  wall  is  a  most  important  factor 
in  maintaining  a  normal  position  of  the  uterus. 

The  Mobility  and  Position  of  tlie  Uterus. — The  corpus  uteri 
is  much  more  mobile  than  the  cervix ;  it  moves  up  and  down 
with  every  breath  the  woman  draws.  It  changes  its  position 
with  her  posture :  descending  in  the  erect,  ascending  in  the 
supine  posture.  The  fundus  is  elevated  by  a  distended  blad- 
der, depressed  by  exerting  the  abdominal  muscles  to  increase 
intra-abdominal  pressure,  as  in  defecation.  It  is  possible  to  ele- 
vate the  fundus  half-way  to  the  navel  by  firm  pressure  through 
the  anterior  vaginal  vault  or  to  drag  the  cervix  down  to  the  vul- 
var orifice  by  forceps.  The  fundus  may  be  pushed  to  one  or  to 
the  other  lateral  pelvic  wall.  The  normal  mobility  of  the  uterus 
is  therefore  great  and  its  possible  mobility  greater  still.  It  fol- 
lows that  the  normal  position  of  the  uterus  may  vary  greatly  and 
that  there  is  no  such  thing  as  one  invariable  position.  There  is, 
however,  a  typical  position  of  the  uterus,  a  wide  departure  from 
which  constitutes  a  pathological  malposition  or  displacement. 

The  typical  position  of  the  uterus  may  be  thus  described  : 
In  the  erect  posture  it  occupies  the  middle  of  the  pelvic  cavity 
between  the  planes  of  the  outlet  and  inlet ;  the  external  os  is  at 
the  level  of  the  upper  edge  of  the  symphysis  and  the  first  or 
second  coccygeal  vertebra  ;  it  lies  in  the  perpendicular  plane  of 
the  spine  of  the  ischia  and  therefore  nearer  the  sacrum  than  the 
symphysis.  The  axis  of  the  cervix  corresponds  with  the  axis  of 
the  pelvic  canal,  and  the  body  of  the  uterus  is  bent  upon  the 
cervix  at  the  isthmus  at  an  angle  of  70  to  100  degrees.  A  per- 
pendicular line  dropped  from  the  fundus  uteri  would  pass  through 
the  middle  of  the  urethrovaginal  septum  ;  one  from  the  internal 
OS,  through  the  rectum  behind  its  middle  ;  one  from  the  external 
OS,  through  the  posterior  quarter  of  the  rectum.  A  horizontal 
line  drawn  from  the  fundus  uteri  passes  through  the  fourth  sacral 
vertebra ;  one  from  the  lowest  portion  of  the  uterus,  the  lower 
end  of  the  anterior  lip  of  the  cervix,  passes  through  the  last 
coccygeal  vertebra. 

The  typical  position  of  the  uterus  in  the  erect  posture  is 
therefore  one  of  anteversion  and  moderate  anteflexion. 


270     Displacements  and  Diseases  of  the  Uterus 

DISPLACEMENTS  OF  THE  UTERUS. 

The  uterus  may  be  turned  on  its  transverse  axis  so  that  the 
intra-abdominal  pressure  is  exerted  on  its  anterior  instead  of  on 
its  posterior  wall — retroversion.  As  the  fundus  and  corpus  are 
much  more  mobile  than  the  cervix,  the  uterus  turned  over  back- 
ward is  almost  invariably  bent  upon  itself — retroflexion.  There 
may  be  an  exaggeration  of  the  normal  ariteversion  and  anteflexion. 
The  uterus  may  be  tilted  or  bent  to  one  side — lateroversiojt,  latero- 
flexion.  It  may  descend  along  the  vagina  and  even  emerge  from 
the  vulva — prolapse  of  the  uterus.  The  corpus  may  be  twisted 
upon  its  pedicle,  the  cervix — torsion  of  the  uterus.  The  hollow 
uterine  muscle  may  be  partially  or  completely  inverted — inver- 
sion  of  the  uterus. 

Retroflexion  and  Retroversion  of  the  Uterus. — A  backward 
displacement  of  the  uterus  by  rotation  on  its  transverse  axis  is, 
with  one  exception,  the  commonest  disease  of  women,  constitut- 
ing almost  a  fifth  of  all  gynecological  cases.  ^  Retroversion 
exists  when  the  uterus  is  turned  on  its  transverse  axis  sufficiently 
for  the  weight  of  the  abdominal  contents  and  the  intra-abdominal 
pressure  to  be  sustained  by  the  anterior  uterine  wall  instead  of 
by  the  posterior  wall.  As  the  fundus  and  corpus  move  back- 
ward the  cervix  moves  forward,  but  the  latter,  being  much  less 
mobile,  does  not  describe  as  great  an  arc  of  a  circle  as  the 
former  ;  hence  there  is  always  some  degree  of  retroflexion  with 
a  retroversion.  These  malpositions  must  be  distinguished  from 
a  retroposition  of  the  uterus,  without  rotation  on  its  transverse 
axis,  which  occurs  in  the  supine  position  if  the  uterine  ligaments 
are  much  relaxed  or  overstretched,  or  which  may  be  the  result  of 
a  tumor  anterior  to  the  uterus,  as  a  myoma,  or  an  overdistended 
bladder.  Retroposition  of  the  uterus  rarely  occasions  symptoms 
and  does  not  as  a  rule  demand  treatment. 

It  has  been  customary  to  describe  three  degrees  of  retrover- 
sion, but  there  is  no  justification  clinically  or  pathologically  for 
the  distinction.  Once  the  anterior  wall  of  the  uterus  feels  the 
weight  of  the  abdominal  contents  and  must  sustain  the  intra- 
abdominal pressure  as  part  of  the  yielding  floor  of  the  abdom- 
inal cavity,  the  uterine  body  will  shortly  be  pushed  as  far 
backward  and  downward  as  the  vagina  and  Douglas's  pouch 
permit,  unless  the  uterus  is  maintained  in  a  certain  position  by 
peritoneal  adhesions. 

The  Causes  of  Retroversion. — By  far  the  commonest  cause  of 
retroversion  is  the  increased  weight  of  the  uterus  and  the 
decreased  tonicity   of   its  ligaments   following  childbirth.      Im- 

^  17.74  pc  cent.,  according  to  the  statistics  of  Winckel,  Lohlein,  and  Sanger.. 


The  Causes  of  Retroversion  271 

proper  management  of  the  puerperium  naturally  increases  the 
predisposition  to  displacement.  If  the  woman  is  allowed  too 
great  freedom  of  movement  in  bed  ;  if  she  sits  up  or  stands  too 
soon  ;  if  she  is  allowed  to  strain  too  hard  in  defecation  ;  to  lift 
her  baby  or  make  any  physical  effort  in  the  early  puerperium 
that  much  increases  intra-abdominal  pressure,  the  uterus  is  likely 
to  turn  over  backward.  It  should  always  be  remembered  that 
involution  of  the  uterus  and  its  ligaments  is  not  completed  for 
six  weeks  after  childbirth.  The  patient  and  often  her  physician 
are  disposed  to  disregard  all  precautions  at  the  end  of  the  con- 
ventional lying-in  period  of  four  weeks.  As  a  matter  of  fact, 
backward  displacement  occurs  rather  more  commonly  between 
the  fourth  and  sixth  weeks  than  during  the  time  the  woman  of  the 
well-to-do  classes  remains  in  her  room.  A  sudden  violent  jolt 
or  jar  stands  next  in  frequency  to  childbirth  as  a  cause  of  retro- 
version. Basket  ball  is  responsible  in  recent  years  for  many 
cases  in  young  women.  Riding  on  a  side  saddle,  especially  if  the 
woman  rides  hard  and  jumps,  causes  more  displacements  than  any 
other  form  of  exercise.  Such  an  accident  as  a  fall  from  a  top  of 
a  coach,  or  downstairs,  or  from  a  carriage,  has  thrown  the  uterus 
over  backward.  Inflammation  of  the  uterine  appendages,  their 
prolapse  into  Douglas's  pouch  by  their  increased  weight,  their 
fixation  there  by  adhesions,  frequently  cause  a  backward  dis- 
placement of  the  fundus,  which  is  pulled  upon  by  the  tubes  and 
the  ovarian  hgaments. 

A  long-continued  habit  of  allowing  the  bladder  to  become 
overdistended  unquestionably  predisposes  to  retroversion.  Young 
girls  should  be  cautioned  against  this  fault,  which  is  often 
unconsciously  acquired  on  account  of  the  numerous  situations  in 
a  woman's  life  making  urination  embarrassing  or  inconvenient 
for  a  long  period  of  time. 

Retroversion  may  be  congenital  as  the  result  of  arrested 
development.  It  is  claimed  that  the  posterior  wall  in  such  cases 
develops  less  rapidly  than  the  anterior  wall  and  acts  upon  the 
latter  like  the  string  of  a  bow,  pulling  it  backward  and  bending 
it  on  itself  A  considerable  number  of  retroversions  may  be 
traced  to  the  influence  of  the  vagina  upon  the  cervix.  If,  for 
example,  the  supports  of  the  posterior  vaginal  wall  are  injured 
and  a  rectocele  develops,  the  posterior  lip  of  the  cervix  is  pulled 
downward  and  forward,  throwing  the  fundus  and  corpus  back- 
ward. A  laceration  of  the  vaginal  sulci,  therefore,  may  be  the 
primar}'  cause  of  a  retroversion  of  the  uterus. 

Again,  if  the  vaginal  portion  of  the  cervix  is  unnaturally 
long,  it  must  be  deflected  forward  by  the  course  of  the  vaginal 
canal,  thus   throwing   the  fundus   backward.     An  elongation  of 


272      Displacements  and   Diseases  of  the  Uterus 

the  vaginal  portion  of  the  cervix,  therefore,  may  be  the  cause  of 
retroversion.  Cicatricial  contraction  of  the  anterior  vaginal  wall 
following  labor  or  extensive  ulceration  has  a  tendency  to  pull  the 
anterior  lip  of  the  cervix  forward  and  thus  to  throw  the  fundus 
over  backward. 

The  Symptoms  of  Retroversion. — The  typical  subjective  symp- 
toms of  retroversion  are  backache,  aggravated  by  exertion  or 
prolonged  standing  on  the  feet;  a  feeling  of  weight  and  bearing- 
down  in  the    pelvis,  menorrhagia,  and  leukorrhea. 

The  half  turn  or  fold  of  the  broad  ligament  on  itself  in  re- 
troversion obstructs  the  venous  circulation  and  causes  a  passive 
congestion  ;  hence,  in  addition  to  the  menorrhagia  and  leukor- 
rhea which  indicate  a  congestion  and  in  time  a  hypertrophy  of 
the  endometrium,  there  is  engorgement  of  the  myometrium, 
an  increase  in  the  weight  and  size  of  the  womb,  and  eventually 
a  chronic  metritis.  There  is  also  an  interference  with  the  circu- 
lation of  the  hemorrhoidal  veins,  and  as  a  result  hemorrhoids 
develop.  The  pull  upon  the  parametrium  between  uterus  and 
bladder  and  the  pressure  of  the  cervix  on  the  neck  of  the  latter 
give  rise  to  vesical  irritability  and  frequent  urination  or  dysuria. 

The  pressure  of  the  fundus  on  the  rectum  may  cause  an  ob- 
stinate constipation,  which  is  aggravated  by  the  indisposition  of 
the  patient  to  strain  at  defecation  on  account  of  the  bearing-down 
sensation  caused  by  increased  intra-abdominal  pressure.  The 
prolapse  of  the  ovaries  accompanying  retroversion  congests  them 
and  may  produce  ovarian  pains. 

The  pressure  of  the  fundus,  often  tilted  to  one  side,  upon  the 
sacrosciatic  plexus  may  cause  neuralgic  pains  running  down  the 
limb  or  numbness  and  even  some  loss  of  power  in  a  lower  ex- 
tremity. Reflex  pains,  aches,  and  neuroses  are  common.  There 
is  usually  a  pain  or  ache  on  the  top  of  the  head,  in  the  occipital 
region,  or  in  the  nape  of  the  neck.  The  coccyx  may  be  the  seat 
of  a  reflex  pain  simulating  true  coccygodynia.  Neurasthenia 
and  hysteria  to  a  profound  degree  may  be  the  ultimate  result  of 
a  long-neglected  retroversion.  High  fever  has  been  observed 
immediately  after  an  acute  retrodisplacement  of  the  uterus. 

Retroversion  may  be  accidentally  discovered  in  women  who 
have  not  exhibited  a  single  symptom  of  the  displacement. 

The  diagnosis  of  retroversion  is  made  by  a  bimanual  exam- 
ination. The  hand  upon  the  abdomen  fails  to  find  the  fundus 
where  it  is  usually  situated  behind  the  symphysis,  and  the  finger 
in  the  vagina  traces  the  uterine  body  running  across  the  poste- 
rior vaginal  vault  toward  the  sacrum,  while  the  abdominal  hand 
makes  pressure  from  above ;  the  angle  of  flexion  may  also 
be  felt  above   the  posterior   fornix   of  the    vagina.      The   posi- 


The  Treatment  of  Retroversion  273 

tion  and  direction  of  the  cervix,  on  which  great  stress  is  some- 
times laid,  are  of  little  importance.  In  a  typical  retroversion  the 
cervix  points  toward  the  symphysis  instead  of  toward  the  sacrum  ; 
but  in  a  sharp  retroflexion  it  may  not  do  so,  and  it  may  be 
directed  toward  the  symphysis  in  an  exaggerated  anteflexion, 
especially  if  the  anteflexed  uterus  is  retroposed,  as  it  sometimes  is. 

The  Treatment  of  Retroversion. — It  is  necessary  in  practice 
to  consider  separately  and  to  treat  differently  retroversion  in  the 
puerperium,  acute  retroversion  from  an  accident  or  strain,  and 
chronic  retroversion  which  has  probably  existed  a  considerable 
time.  It  is  necessary,  also,  to  take  into  account  the  circum- 
stances of  the  patient  and  her  ability  to  undergo  a  prolonged 
treatment  involving  a  life  of  comparative  leisure  or  at  least  free- 
dom from  hard  work. 

The  Treatment  of  Retroversion  Originating  in  the  Puerperium. 
— Every  woman  should  be  examined  between  the  third  and  the 
fourth  week  after  her  delivery  at  term,  or  earlier  after  a  miscar- 
riage, when  she  begins  to  walk  about  her  room.  If  a  retrover- 
sion is  discovered,  the  uterus  should  be  replaced,  and  the  patient 
should  be  instructed  to  assume  the  knee-chest  posture  for  five 
minutes  night  and  morning  while  undressed  for  bed;  from  the 
knee-chest  position  she  should  be  shown  how  to  gently  sink  on 
one  side  in  the  Sims'  position,  in  which  she  should  lie  for  ten  or 
fifteen  minutes  before  getting  up.  As  the  vulva  usually  gapes 
shortly  after  confinement,  no  special  precautions  are  necessary, 
as  a  rule,  to  insure  the  entrance  of  air  into  the  vagina  so  that 
atmospheric  pressure  may  assist  gravity  in  the  reposition  of  the 
womb.  If  there  is  any  doubt  on  this  point,  a  finger  or  the  nozzle 
of  a  vaginal  syringe  should  be  inserted  into  the  vaginal  orifice 
after  the  assumption  of  the  knee-chest  posture.  A  pessary  is 
contraindicated  at  this  time  on  account  of  the  weight  of  the 
uterus,  the  relaxation  of  its  ligaments  and  of  the  vagina. 
Many  a  case  of  retroversion  in  the  puerperium  is  cured  perma- 
nently by  this  simple  postural  treatment  which,  if  neglected, 
would  become  unmanageable  except  by  an  operation  or  the 
indefinite  use  of  a  pessary. 

Whether  the  uterus  is  retroverted  or  not  at  the  first  examina- 
tion, a  second  examination  should  invariably  be  made  at  the  end 
of  six  weeks,  when  involution  is  complete.  If  a  retroversion 
is  then  discovered,  the  uterus  should  be  replaced,  a  suitable 
pessary  inserted,  and  the  patient  should  be  given  an  eight  weeks' 
course    of    medical    gymnastics    and    abdominal     massage  ^    to 

^  A  system  has  been  perfected  in  the  institutes  of  Germany  and  Sweden  which  is 
very  effective.      The  author  puts  his  patients  under  the  charge  of  a  graduate  of  these 
institutions,  who  supervises  the  exercises  and  gives  the  massage. 
18 


2/4     Displacements  and   Diseases  of  the  Uterus 

strengthen  the  pelvic  muscles  and  ligaments,  and  to  improve  the 
pelvic  circulation.  At  the  end  of  eight  weeks  the  pessary  is 
removed.  The  patient  is  examined  two,  four,  and  six  weeks  later. 
If  the  uterus  is  found  at  the  last  examination  in  good  position, 
the  patient  may  be  dismissed  as  cured.  A  large  proportion,  if  not 
the  majorit}',  of  cases  thus  treated  are  permanently  cured.  If  the 
retroversion  returns  after  the  removal  of  the  pessary,  the  patient 
should  be  told  that  the  uterus  will  probably  not  remain  in  place 
without  some  form  of  artificial  support,  and  she  should  be  offered 
the  choice  of  a  continued,  probably  an  indefinite,  use  of  the  pes- 
sary and  a  radical  cure  by  an  operation.  The  advantages  and  dis- 
advantages of  the  two  plans  of  treatment  should  be  explained  to 
her,  and  she  should  be  allowed  to  make  her  own  choice  without 
being  urged  by  the  physician  to  one  course  or  the  other. 

TJic  Treatment  of  an  Acute  Retroversion  the  Restilt  of  an 
Accident. — If  a  woman  meets  with  an  accident  and  suffers  from 
pelvic  pain  and  backache  afterward,  she  should  be  examined.  If 
a  retroversion  is  discovered,  the  uterus  should  be  immediately 
replaced.  Both  the  examination  and  reposition  should  be  done 
under  anesthesia  if  the  patient  is  a  young  unmarried  girl.  If  the 
uterus  is  replaced  shortly  after  its  acute  displacement,  it  nearly 
always  remains  in  good  position  without  support.  A  pessary, 
therefore,  should  not  be  inserted.  The  patient,  however,  should 
be  instructed  to  take  the  knee-chest  posture  night  and  morning. 
A  week  or  more  after  the  reposition  another  examination  should 
be  made.  If  the  uterus  remains  in  good  position,  the  displace- 
ment is  probably  permanently  cured. 

Tlie  Treatment  of  a  Chronic  Retroversion. — If  a  backward  dis- 
placement has  existed  for  a  considerable  time,  when  the  patient 
first  comes  under  a  physician's  observation,  the  uterus  should  be 
replaced  and  a  pessary  should  be  inserted.  A  course  of  medical 
gymnastics  and  massage  should  be  recommended,  with  the  knee- 
chest  posture  night  and  morning.  At  the  end  of  eight  weeks  the 
pessary  should  be  removed  and  an  attempt  made  to  go  without  it, 
the  patient  being  instructed  to  take  the  knee-chest  posture  twice 
a  day.  An  examination  should  be  made  at  the  end  of  one,  two, 
and  six  weeks.  If  the  uterus  remains  in  good  position  at  the  last 
examination,  she  is  probably  cured,  though  the  woman  who  has 
had  a  retroversion  is  likely  to  have  it  again  if  she  bears  children 
or  is  exposed  to  the  other  causes  that  are  responsible  for  a  back 
ward  di.splacement  of  the  uterus.  If  the  retroversion  returns  after 
the  removal  of  the  pessary,  the  uterus  will  probably  always 
require  some  artificial  support.  This  fact  should  be  stated  to  the 
patient,  who  should  be  offered  the  choice  of  an  indefinite  use  of 
a  pessary  or  of  the  radical  cure  by  operation. 


The  Treatment  of  Retroversion 


275 


Tlic  Reposition  of  a  Rctrovcrtcd  Uterus. — The  best  and  most 
con\-enient  plan  of  replacing  a  retroverted  uterus  is  the  bimanual 


Fig.  2S7. — Bimanual  reposition  of  tlie  uterus,  first  step. 


Fig.  288. — Bimanual  reposition  of  the  uterus,  second  step. 

manceuver  of  Schultze.  The  patient's  clothing  is  loosened;  she 
is  placed  in  the  dorsal  position  with  the  thighs  well  flexed  on  the 
abdomen,  the  legs  on  the  thighs,  the  pelvis  slightly  elevated,  and 


276     Displacements  and  Diseases  of  the  Uterus 

the  trunk  -flexed  just  above  the  pelvis.  Two  fingers  of  the  left 
hand  are  inserted  in  the  vagina,  elevating  the  retroverted  uterus  as 
high  as  possible  by  pressure  through  the  posterior  vaginal  vault. 
The  fingers  of  the  other  hand  depress  the  abdominal  wall 
until  their  tips  are  hooked  under  the  fundus  uteri,  which  is 
pulled  forward  while  the  internal  fingers  are  quickly  shifted  from 
the  posterior  to  the  anterior  vaginal  vault,  pressing  the  cervix 
and  lower  uterine  segment  back  as  the  fundus  is  pulled  forward. 


Fig.  289. — Bimanual  reposition  of  the  uterus,  third  step 


Finally,  the  physician,  to  assure  himself  that  the  position  of  the 
uterus  is  good,  grasps  the  fundus  and  body  between  the  internal 
fingers  and  the  fingers  on  the  abdominal  wall.  It  is  sometimes 
easier  to  replace  the  uterus  by  making  the  fundus  describe  a 
semicircle  from  the  sacrum  to  the  symphysis,  making  it  rotate 
upon  an  anteroposterior  axis  instead  of  upon  a  transverse  axis. 
To  replace  a  retroverted  uterus  by  bimanual  manipulation,  the 
vagina  must  be  capacious,  the  abdominal  walls  perfectly  relaxed 
and  not  too  fat,  and  the  woman  herself  not  too  sensitive.  These 
conditions  are  not  always  present,  and  if  they  are  not,  the 
bimanual  reposition  may  be  impossible  without  an  anesthetic.  In 
such  a  case  the  patient  is  put  in  the  knee-chest  position,  a  Sims' 


The  Treatment  of  Retroversion  277 

speculum  is  inserted,  and  the  posterior  vaginal  wall  well  re- 
tracted. The  cervix  is  seized  with  a  tenaculum,  pulled  downward 
and  backward,  while  the  fundus  and  corpus  are  pushed  forward 
by  pressure  through  the  posterior  vaginal  vault  exerted  by  means 
of  a  uterine  repositor  (Fig.  290)  or  a  pledget  of  wool  on  the  end 
of  a  forceps,  the  instrument  being  used  as  a  lever  with  the  ful- 
crum supplied  by  the  blade  of  the  speculum. 

It  is  often  possible  to  dispense  with  the  tenaculum  and  to 
replace  the  uterus  with  the  repositor  alone. 

At  long  intervals  one  fails  to  replace  a  retroverted  uterus 
by  both  of  these  plans,  although  there  are  no  adhesions  and  the 
uterus  is  perfectly  mobile.  In  such  cases  it  is  justifiable  to  use 
the  uterine  sound  as  a  repositor,  if  the  strictest  precautions  are 
taken  to  avoid  infection  of  the  uterine  cavity.  This  may  be  done 
by  boiling  a  bivalve  speculum,  a  dressing  forceps,  and  the  sound 
bent  in  a  good  curve  ;  inserting  the  speculum  and  distending  its 
blades  widely,  wiping  off  the  cervix  with  cotton  balls  soaked  in  a 
I  :  1000  sublimate  solution,  inserting  the  sound  directly  into  the 


Fig.  290. — iJterine  repositor. 


OS  without  allowing  it  to  touch  anything  but  the  inner  surfaces 
of  the  speculum  blades,  passing  it  to  the  fundus,  rotating  the 
handle  with  a  wide  circular  sweep  so  as  to  bring  the  con- 
cavity of  the  sound  upward,  removing  the  speculum  and  depress- 
ing the  handle  of  the  sound  firmly,  but  not  with  sufficient  force 
to  penetrate  the  uterine  muscle.  In  women  who  are  extremely 
obese  and  very  nervous  or  apprehensive  this  will  be  found  the 
easiest  method  for  both  patient  and  physician  ;  but  the  use  of  a 
sound  as  a  repositor  should  be  restricted  as  much  as  possible, 
and  the  greater  one's  experience,  the  less  will  be  his  need  for  it. 
This  method,  however,  is  a  justifiable  and  an  advantageous  one 
on  rare  occasions. 

The  Treatment  of  Retroversion  Coniplicated  by  Aelhesions  and 
Fixation  of  the  Uterus. — Not  infrequently  all  attempts  to  replace 
the  uterus  fail  on  account  of  adhesions  binding  the  fundus  to  the 
rectum  or  uniting  the  uterus  and  its  appendages  to  neighboring 
intrapelvic  structures.  Usually  the  adhesions  can  actually  be  felt 
when  the  uterus  is  elevated  and  the  adhesive  bands  are  put  on  a 
stretch;  ordinarily  the  tubes   and   ovaries   are   displaced,   fixed^ 


278      Displacements  and   Diseases  of  the  Uterus 

enlarged,  and  infiltrated,  and  these  conditions  are  plainly  recog- 
nized in  a  bimanual  examination.  Occasionally,  however,  no 
adhesions  can  be  demonstrated  by  one's  sense  of  touch  ;  yet  they 
may  be  assumed  to  be  present  if  none  of  the  methods  just 
described  succeeds  in  replacing  the  uterus,  or  if,  as  soon  as  the 
womb  is  replaced,  it  immediately  returns  to  its  former  position 
when  released  from  the  bimanual  grasp  of  the  examining  physi- 
cian. 

If  the  diagnosis  of  pelvic  adhesions  is  made  the  patient 
should  be  given  the  choice  of  two  plans  of  treatment:  an  abdom- 
inal section  with  the  necessary  treatment  of  the  diseased  append- 
ages, severing  adhesions,  and  suspending  the  uterus,  or  a  pro- 
longed course  of  vaginal  packing  with  tampons  to  gradually  ele- 
vate the  uterus,  and  the  subsequent  use  of  a  pessary.  It  should 
be  stated  that  the  latter  course  is  tedious,  trying  to  the  patient's 
nervous  system,  and  uncertain  in  its  results;  but  in  many  patients 
there  is,  after  weeks  of  treatment,  symptomatic  relief,  and  in  some 
the  uterus  remains  in  place  supported  by  a  pessary ;  in  a  small 
minority  of  cases  there  is  a  permanent  cure  without  the  necessity 
of  artificial  support  of  any  kind.  By  stating  the  facts  and  point- 
ing out  the  relative  advantages  and  disadvantages  of  the  two 
plans  of  treatment,  allowing  the  woman  to  make  her  own  choice, 
the  physician  is  beyond  criticism,  as  he  would  not  be  if  he  urged 
one  plan  or  the  other  on  his  patient. 

If  the  palliative  treatment  is  decided  upon,  it  should  be  car- 
ried out  as  follows :  The  patient  is  placed  in  a  knee-chest  posi- 
tion ;  a  Sims'  speculum  is  inserted  and  the  posterior  vaginal  vault 
is  w^ell  retracted;  the  fundus  uteri  is  pressed  as  far  forward  as 
possible  by  the  repositor  without  causing  the  patient  too  much 
pain;  tampons  of  lamb's  wool  are  packed  firmly  in  the  posterior 
vaginal  vault  with  an  Emmet  curetment  forceps  held  with  the 
concavity  of  the  curve  in  the  instrument  downward;  when  the 
posterior  vault  is  filled  to  the  utmost,  other  tampons  are  placed 
anterior  to  the  cervix,  and  others  still  in  the  vaginal  canal  to 
support  those  above.  Each  tampon  before  its  insertion  is  dusted 
with  powdered  boracic  acid.  The  patient  is  in.structed  to  remove 
the  tampons  by  the  string  attached  to  them  at  the  end  of  forty- 
eight  hours,  just  before  her  next  visit  to  the  doctor's  office,  and 
to  take  a  vaginal  douche  of  boracic  acid,  5ij  to  Oij.  The  tam- 
pons are  renewed  every  other  day,  the  treatment  naturally  being 
intermitted  during  menstruation.  If  the  woman  has  patience  to 
persist  in  this  treatment  for  ten  or  twelve  weeks,  there  is  often 
an  astonishing  improvement  in  the  physical  signs  of  the  former 
pelvic  disease  and  a  most  gratifying  relief  of  symptoms.  Large, 
distended,  adherent  tubes   may  become  practically  normal  in  size 


The  Treatment  of  Retroversion 


2/9 


and  position,  the  uterus  is  freely  movable,  is  easily  supported 
by  a  pessary,  and  sometimes  remains  in  perfect  position  without 
support.  On  the  contrary,  there  are  some  patients  who  can  not 
endure  local  treatment,  who  are  not  willing  or  able  to  spare  the 
time  for  it,  or  who  do  not  care  to  undertake  it  in  view  of  the 
uncertainty  of  its  results.  Such  patients  will  elect  the  operative 
treatment.  Moreover,  if  the  local  treatment  fails,  as  it  may,  and 
often  does,  the  choice  must,  eventually  be  made  of  enduring  the 
symptoms  of  a  fixed  retroverted  uterus  or  of  being  cured  by  an 
operation. 

The  Use  of  Pessaries  in  the  Treatment  of  Retroversion. — There 
has  been  a  reaction  against  the  indiscriminate  use  of  pessaries 
which  has  gone  too  far.  No  one  can  successfully  manage  a 
number  of  cases  of  retroversion,  no  one  can  retain  a  considerable 


Fig.   291. — Hodge    pes- 
sary for  retroversion. 


Fig.  292. — Smith  pessary 
for  retroversion. 


Fig-  293- — Thomas  pes- 
sary for  retroversion. 


proportion  of  his  patients  who  has  not  mastered  the  art  of  sup- 
porting a  uterus  in  this  manner. 

A  pessary  ^  should  be  made  of  hard  rubber,  and  for  retro- 
version should  have  the  shapes  designed  by  Hodge,  Albert 
Smith,  and  Thomas.  Various  sizes  of  these  three  pessaries 
should  be  at  hand.  The  Smith  pessary  is  on  the  whole  the 
most  suitable  in  the  majority  of  cases.  The  narrow  anterior  bar 
and  the  bend  in  it  to  avoid  pressure  on  the  urethra  are  great  advan- 
tages. The  broad  anterior  bar  of  a  Hodge  pessary,  however, 
and  its  lack  of  downward  curve  make  it  available  in  a  relaxed 
vagina  which  could  not  support  the  Smith  pessary.  The  advan- 
tage of  a  Thomas  pessary  lies  in  its  thick  posterior  bar,  which 
distributes  the  pressure  on  the  posterior  vaginal  vault,  thus  avoid- 

1  From  TTzcsao^,  an  oval-shaped  stone  used  in  the  ancient  game  of  draughts. 


28o     Displacements  and   Diseases  of  the  Uterus 

ing  ulceration  of  the  vaginal  mucous  membrane  better  than  if 
the  pressure  were  concentrated  on  the  narrow  bar  of  the  other 
pessaries. 

It  should  be  remembered  that  by  oiling  a  hard- rubber  pessary 
and  heating  it  over  a  spirit-lamp  it  may  be  bent  in  any  shape  the 
physician  desires  to  suit  an  individual  case.  By  immersing  it  in 
cold  water  the  shape  given  it  is  permanently  retained.  If  a 
pessary  is  immersed  in  boiling  water,  as  is  sometimes  mistakenly 
done  to  cleanse  it,  it  reassumes  the  shape  of  a  simple  ring  from 
which  it  was  originally  bent.  The  pessary  acts  as  a  lever  in  the 
vagina,  with  the  long  arm  anteriorly  receiving  the  weight  of  the 
intrapelvic  and   abdominal  contents,  the   fulcrum   being  the  pos- 


Fig.  294. — The  retroversion  pessary  in  position.      The  arrow  shows  the  direction  of 
the  traction  of  the  posterior  vaginal  wall  upon  the  cervix. 


terior  vaginal  wall  where  the  posterior  curve  of  the  pessary  be- 
gins and  the  force  of  the  short  arm  of  the  lever  being  exerted 
upon  the  uterosacral  ligaments,  pulling  the  cervix  back  and  thus 
tilting  the  fundus  forward.  The  pessary  is  held  in  the  vagina  by 
the  shape  of  the  canal,  S-shaped  in  its  curve  and  funnel-shaped 
from  above  downward,  by  the  cervix  over  which  the  pos- 
terior bar  is  hooked,  and  also  by  the  grasp  of  the  elastic  and 
muscular  tissues  in  the  vaginal  wall.  The  funnel  shape  of  the 
vaginal  canal  is  contributed  by  the  .strong  muscles  that  encircle  it 
posteriorly,  the  levator  ani  and  the  bulbocavernosus  muscles.  If 
these  muscles  are  injured  or  very  much  relaxed  there  is  no  ful- 
crum afforded  the  lever  pessary,  the  posterior  transverse  bar  is  not 


The  Treatment  of  Retroversion  281 

pressed  firmly  into  the  posterior  vaginal  vault  behind  and  above 
the  cervix,  the  prolapsed  posterior  vaginal  wall  pulls  the  posterior 
bar  downward  and  forward,  and  the  vagina  being  no  longer  a 
funnel  with  the  small  end  downward,  the  pessary  is  free  to  slip 
out.  Hence  an  extensive  injury  of  the  pelvic  floor  in  labor 
makes  the  use  of  a  pessary  impossible.  A  perineorrhaphy  must 
be  performed  before  it  can  be  employed. 

Other  contraindications  to  the  use  of  a  pessary  are  fixation  of 
the  uterus  in  a  posterior  position,  prolapsed  and  adherent  ovaries. 

The  author  is  averse  to  the  use  of  a  pessary  in  young  un- 
married girls.  The  vagina  is  so  narrow,  especially  in  its  entrance, 
that  it  is  difficult  to  insert  a  pessary  large  enough  to  support  the 
uterus,  and  the  necessity  for  frequent  examinations  while  the 
pessary  is  worn  is  most  objectionable. 

The  insertion  of  a  pessary  should  be  conducted  as  follows  : 
The  uterus  must  first  be  replaced  in  perfect  position.  The 
pessary  is  not  a  repositor  and  will  do  more  harm  than  good  if 
the  uterus  is  tetroflexed  over  its  posterior  bar,  as  it  surely  will 
be  unless  the  fundus  is  in  perfect  anterior  position,  before  the 
pessary  is  inserted. 

The  patient  is  placed  in  the  dorsal  position.  The  pessary  is 
cleansed  with  soap  and  water  and  its  posterior  bar  is  anointed 
with  an  unguent.  The  physician  takes  the  anterior  bar  of  the 
pessary  between  the  thumb  and  forefinger  of  his  right  hand, 
holding  it  obliquely  with  the  concavity  of  the  posterior  curve 
directed  downward  ;  with  the  forefinger  of  the  left  hand  pressure 
is  exerted  in  the  right  posterior  vaginal  sulcus.  The  pessary  is 
then  inserted  in  the  elongated  obHque  diameter  of  the  vagina, 
being  turned  on  its  long  axis  as  it  approaches  the  vaginal  vault 
to  bring  the  concavity  of  the  posterior  curvature  upward.  This 
movement  brings  the  posterior  bar  in  front  of  the  cervix.  The 
forefinger  of  the  left  hand  is  inserted  in  the  vagina  behind  the 
pessary,  is  placed  over  the  posterior  bar,  by  turning  the  dorsal 
surface  of  the  finger  upward  and  passing  the  finger-tip  through 
the  ring  of  the  pessary.  The  posterior  bar  is  then  pressed  back- 
ward over  the  cervix  until  it  slips  behind  it  into  the  posterior 
vaginal  vault.  The  pessary  should  be  long  enough  to  reach  from 
the  posterior  vault  of  the  vagina  to  about  the  middle  of  the 
urethra,  and  broad  enough  to  stretch  across  the  vagina  with  the 
lateral  bars  touching  the  lateral  walls  without  pressing  them  firmly. 
It  should  be  possible  to  pass  the  finger-tip  easily  anywhere  be- 
tween the  pessary  and  the  vaginal  walls.  While  the  woman 
wears  a  pessary  she  should  be  instructed  to  take  a  douche  of 
boracic  acid^  5ij  to  Oij,  after  each  menstrual  period,  beginning 
twenty-four  hours  after  the  cessation  of  the  flow,  and  repeating 


282     Displacements  and  Diseases  of  the  Uterus 

the  douche  daily  for  a  couple  of  days.  Another  douche  should 
be  taken  midway  between  the  period.  Daily  douches  are  un- 
necessary. The  patient  must  report  to  her  physician  every  six  or 
eight  weeks.  At  these  visits  the  pessary  is  removed  and  the  posi- 
tion of  the  uterus  is  investigated.  The  posterior  vaginal  vault  is 
carefully  inspected  through  a  bivalve  speculum,  and  if  the  mucous 
membrane  is  healthy,  the  pessary  is  cleansed  with  soap  and 
water,  anointed  with  an  unguent,  and  reintroduced.  Every  woman 
whose  uterus  is  maintained  in  position  by  a  pessary  for  a  long 
time  will  exhibit   some   redness  of  the   posterior   vaginal  vault 


Fig.  295. — Insertion  of  a  pessary. 


where  it  is  rubbed  by  the  posterior  bar  of  the  pessary,  and  occa- 
sionally, perhaps  only  once  in  two  or  three  years,  there  will  be 
an  actual  superficial  ulceration.  If  ulceration  is  threatened  or 
has  actually  occurred,  the  pessary  must  be  left  out  for  two  weeks, 
the  patient  taking  a  daily  boracic  acid  douche.  The  uterus  may 
thus  be  maintained  in  good  position  indefinitely,  the  woman  being 
perfectly  comfortable.  The  author  has  under  his  care  cases  of 
fifteen  years'  duration  in  which  a  pessary  has  been  worn  con- 
stantly. If  the  patient  elects  this  treatment  after  a  full  knowl- 
edge of  the  facts  and  of  the  possibility  of  a  permanent  cure  by 


The  Treatment  of  Retroversion  283 

operative  treatment,  she  has,  of  course,  a  perfect  right  to  choose 
her  own  course,  and  indeed  will  do  so,  going  to  another  physi- 
cian if  the  original  attendant  has  not  the  ability  and  skill  to  man- 
age her  case  as  she  is  determined  it  shall  be  managed. 

The  Operative  Treatment  of  Retroversion. — Various  plans  of 
correcting  a  retroversion  by  surgical  means  have  been  proposed : 
fixing  the  fundus  to  the  peritoneum  of  the  vesico-uterine  pouch 
(Schiicking,  Diihrssen,  Mackenrodt);  shortening  the  uterosacral 
ligaments  ;  an  intrapelvic  shortening  of  the  round  ligaments  by 
folding  them  on  themselves  (Wylie,  Mann,  Dudley);  shorteningthe 
round  ligaments  by  pulling  them  out  of  the  inguinal  canals  (Alquie, 
Alexander,  Adams) ;  and  suspending  the  fundus  uteri  from  the 
anterior  abdominal  wall  (Olshausen,  Lawson  Tait).  Of  these 
methods,  the  last  two  alone  are  to  be  recommended.  The  various 
plans  of  vaginal  fixation  must  be  condemned  on  account  of 
dangerous  complications  in  subsequent  pregnancies  and  labors. 
No  other  operative  procedures  have  given  such  bad  results  in 
childbirth.  Moreover,  the  proportion  of  recurrences  after  vaginal 
fixation  is  the  largest  yielded  by  any  of  the  operations  for  retro- 
version. Intrapelvic  shortening  of  the  round  ligaments  cannot 
be  recommended  because  of  the  weak  fixed  point  in  the  anterior 
end  of  the  round  ligament  upon  which  the  success  of  the  opera- 
tion depends.  The  author's  objection  to  these  operations  is  not 
merely  theoretical,  but  is  based  upon  practical  trials. 

The  intraperitoneal  shortening  of  the  round  ligaments  by  abdominal  or  vaginal 
section  has  exercised  the  ingenuity  of  many  operators.  Wylie  folds  them  once  on 
themselves  and  sews  the  folds  together ;  Dudley  sews  the  folds  together  and  fastens 
them  to  the  anterior  uterine  wall  ;  Mann  folds  them  twice  on  themselves  by  means 
of  a  special  forceps  and  sews  the  three  folds  together.  Other  procedures  are : 
to  dissect  the  ligaments  out  of  the  peritoneum,  to  fold  and  sew  the  folds  together,  and 
to  bury  the  ligaments  again  under  the  peritoneum ;  to  cut  them  loose  at  the  internal 
inguinal  ring  after  ligation,  to  dissect  them  out  and  to  use  the  ligaments  as  a  thick 
suture  which  is  fastened  in  the  abdominal  wound  or  is  carried  through  the  rectus 
muscle  and  the  fascia  and  fastened  above  the  latter;  to  carry  a  fold  of  the  ligament 
through  the  broad  ligament  back  of  the  uterus  and  to  unite  it  with  its  fellow  of  the 
opposite  side. 

Shortening  of  the  uterosacral  ligaments  is  a  difficult  pro- 
cedure, the  utility  of  which  has  not  yet  been  demonstrated.  Of 
the  two  operations  recommended,  shortening  the  round  ligaments 
in  the  inguinal  canal  is  the  superior  for  the  following  -reasons :  It 
is  perfectly  safe  ;  there  are  no  recorded  cases  of  difficulty  in 
subsequent  labors;  the  proportion  of  recurrences  is  the  least  of 
any  of  the  operations  for  retroversion  ;  there  is  no  disturbance 
whatever  of  the  normal  anatomical  relations  of  the  uterus.  The 
danger  of  hernia  can  be  avoided  by  proper  suturing. 

No  one  can  perform  the  two  operations  side  by  side  over  a 
period  of  years  and  in  a  large  number  of  cases  without  admitting 


284     Displacements  and  Diseases  of  the  Uterus 

the  superiority  of  the  modern  Alexander  operation  as  modified  by 
Edebohls.  It  is  unfortunate,  therefore,  that  the  operation  has  a 
somewhat  limited  field.  There  should  be  no  intrapelvic  disease  ; 
no  pelvic  adhesions  ;  the  woman  should  not  be  too  old  nor  too  fat ; 


Fig.  296.- — -Anatomy  of  the  inguinal  canal  :  a.  Aponeurosis  of  the  external 
oblique;  b,  superficial  epigastric  vessels;  c,  epigastric  vessels;  d,  ilio-inguinal  nerve; 
e,  sections  of  transversalis  and  internal  oblique  muscles ;  f,  vaginal  process  of  peri- 
toneum ;  g,  fold  of  the  transverse  semilunar  fascia  ;  h,  genitocrural  or  spermatic 
nerve  ;  i,  aponeurosis  of  external  oblique  muscle  ;  j,  inguinal  ligament ;  k,  super- 
ficial femoral  fascia  ;  /,  external  pudic  vein  ;  m,  transversalis  fascia  ;  n,  round  liga- 
ment and  its  artery  ;  o,  fibers  of  insertion  of  the  round  ligament ;  p,  upper  column  of 
the  ring;  q,  branch  of  the  external  pudic  vein  ;  r,  position  of  the  pubic  spine  ;  s, 
genital  branch  of  genitocrural  or  external  spermatic  nerve  ;  t,  round  ligament ;  n, 
ilio-inguinal  nerve;  v,  mons  veneris;  %v,  labium  majus  (Waldeyerj. 


the  uterus   should  not  be  too  large  or  heavy,  and    there  should 
not  be  a  decided  prolapsus. 

Shortening  the  Round  Ligaments ;  Alexander's  Operation. — 
The  groins,  the  thighs  a  third  of  the  way  down  should  be  pre- 
pared as  for  an  abdominal  section  (page  600).  The  field  of  opera- 
tion being  displayed,  the  skin  along  the  course  of  the  inguinal  canal 
is  wiped  off  vigorously  with  alcohol  poured  on  a  sterile  gauze  pad. 


The  Treatment  of  Retroversion 


285 


The  operator  places  his  forefinger  on  the  pubic  spine,  his  thumb  on 
Poupart's  ligament,  about  an  inch  and  a  half  intervening  between 
the  two.  The  points  of  the  forefinger  and  of  the  thumb  are 
then  moved  upward  about  a  quarter  of  an  inch  and  an  incision 
through  the  skin  is  made  between  them.  The  fat  and  superficial 
fascia  are  divided  to  the  deep  fascia.  Several  blood-vessels  are 
severed,  the  bleeding  ends  of  which  must  be  seized  by  hemostats. 
All  the  bleeding  must  be  controlled  before  the  deep  fascia  is 
opened,  otherwise  the  difficulty  of  finding  the  round  ligaments  is 
much  increased.  The  fascia  is  incised  just  above  Poupart's  liga- 
ment, the   incision  running  through   the   pillars  of  the  external 


Fig.  297. — Round  ligament,  freed,  but  not  yet  detached. 


inguinal  ring.  On  the  position  of  the  incision  depends  the  ease 
with  which  the  round  ligaments  are  found.  If  it  is  too  high, 
they  may  not  be  located  at  all,  or  only  with  such  difficulty  and 
delay  that  the  operation  is  scarcely  justifiable.  The  inguinal 
canal  being  laid  open  by  the  division  of  the  fascia,  the  edges  of 
the  wound  are  retracted  with  forked  retractors.  The  round  liga- 
ment is  at  once  seen  as  a  whitish  or  pinkish  cord  about  as  large  as 
a  slate-pencil,  running  along  the  floor  of  the  canal.  It  is  picked 
up  by  a  blunt  hook  and  gently  drawn  out  of  the  internal  ring,  the 
genitocrural  nerve  which  accompanies  it  being  avoided.  The  peri- 
toneal investiture  which  soon  appears  is  stripped  back  by  a  gauze 


286     Displacements  and   Diseases  of  the  Uterus 

pad  and  the  Hgament  is  pulled  out  until  it  is  freed  for  at  least  four 
inches.  It  becomes  thicker  and  stronger  as  it  emerges  from  the 
internal  ring,  until  it  may  reach  almost  half  tlie  caliber  of  one's 
Httle  finger.  One  ligament  being  extracted,  the  wound  is  covered 
with  a  gauze  pad  and  the  other  groin,  opposite  the  operator,  is 
opened  in  the  same  way,  except  that  if  the  operator  stands  on 
the  patient's  right  hand,  the  thumb  of  his  left  hand  marks  the 
position  of  the  pubic  spine  and  the  forefinger  is  placed  upon 
Poupart's  ligament  about  one  and  a  half  inches  away. 

Both  ligaments  being  freed  as  far  as  possible  (at  least  four 


Fig.  298. — Round  ligaments  pulled  out  of  inguinal  canal  four  to  six  inches. 


inches,  oftener  more),  they  are  pulled  upon  by  an  assistant, 
while  the  operator  lays  his  outspread  hand  upon  the  hypogas- 
trium,  against  which  he  feels  the  fundus  uteri  bump  as  the  liga- 
ments are  pulled  upon.  The  terminal  ends  of  the  ligaments  are 
cut  off,  they  are  crossed  in  the  middle  line  over  the  mons  veneris, 
and  a  hemostat  fa.stens  them  both  where  they  cross  to  insure  an 
equal  amount  of  traction  on  each  when  they  are  sewed  fast  in  the 
inguinal  canal. 

The  sutures  are  now  inserted.  A  strand  of  formalin  catgut 
(size  No.  3)  on  a  curved  needle  is  passed  through  the  fascia  at 
the    upper    angle   of   the   wound,  the   end   remaining  loose,,  not 


The  Treatment  of  Retroversion 


287 


knotted  ;  the  needle  then  passes  through  the  internal  oblique 
muscle,  goes  through  the  center  of  the  round  ligament,  picks  up 
the  floor  of  the  inguinal  canal,  and  finally  passes  through  Pou- 
part's  ligament.  Four  or  five  turns  are  thus  taken,  in  the  same 
order,  each  one  passing  through  the  center  of  the  round  ligament 
until  the  external  pillars  of  the  ring  are  united.  The  next  turn 
of  the  needle  passes  under  the  round  ligament,  obliterating  the 
external  ring  from  above  downward.  All  the  redundant  portion 
of  the  round  ligament  is  cut  off;  the  same  needle  and  thread  are 


Fig.  299. — Round  ligaments  crossed  and  fastened  togetlier  in  mid-line. 


then  passed  through  the  fascia  alone  midway  between  the  turns 
of  the  continuous  suture  already  in  place,  until  the  suture  ends 
opposite  the  point  where  it  began  and  is  knotted  in  a  triple  knot, 
the  only  one  required.  The  superficial  fascia  and  fat  are  joined 
by  a  continuous  fine  formalin  catgut  suture  in  two  tiers.  The 
skin  is  united  by  a  continuous  suture  of  catgut  or  an  intracuta- 
neous stitch  as  the  operator  prefers.  The  groin  wound  nearest 
the  operator  being  closed,  the  other  one  is  treated  in  the  same 
way,  except  that  a  right-handed  man  naturally  passes  the  needle 


288     Displacements  and  Diseases  of  the  Uterus 

in  reverse  order  through  Poupart's  Hgament,  floor  of  inguinal 
canal,  round  ligament,  oblique  muscle,  and  fascia.  As  the  round 
ligament  is  sewed  in  place  an  assistant  holds  the  hemostat  grasp- 
ing it  in  the  middle  line  of  the  mons  veneris  so  as  to  insure  equal 
traction  on  both  sides.  The  wounds  are  covered  with  silver  foil, 
and  gauze  and  collodion  over  which  are  placed  dry  sterile  gauze 
and  cotton  held  in  place  by  strips  of  oxid  of  zinc  plaster  and  an 
abdominal  binder.  It  is  safer,  but  not  necessary,  to  insert  a 
pessar}'  before  shortening  the  round  ligaments,  which  remains 
in  place  for  six  weeks  after  the  operation.  A  convenient  time 
to  insert  the  pessary  is  after  the  curetment  which  ordinarily  pre- 
cedes an   Alexander  operation,  for  almost  every  case   of  retro- 


Fig.  300. — Deep  tier  of  buried  running  suture  of  formalin  catgut,  embracing 
internal  oblique  and  transversalis  muscles,  round  ligament,  and  Poupart's  ligament. 
Deep  part  of  uppermost  loop  of  suture  (not  showing  in  cut)  passes  at  level  of  and  em- 
braces margins  of  internal  ring:  s.,  Skin;  s.  c.  f.,  subcutaneous  fat;  a.  e.  0.,  apon- 
eurosis of  external  oblique  ;  i.  0.,  internal  oblique  muscle;  ;-.  /;,  round  ligament;  F.  /. , 
Poupart's  ligament. 

version  is  complicated  by  a  chronic  endometritis  with  menor- 
rhagia  and  leukorrhea.  In  a  nulliparous  woman  there  is  apt  to 
be  severe  dysmenorrhea,  which  indicates  a  forcible  and  extreme 
dilatation  of  the  cervical  canal  as  well  as  curetment. 

Uterine  Suspension. — An  abdominal  section  and  suspension 
of  the  fundus  uteri  from  the  anterior  abdominal  wall  are  indicated 
in  the  operative  treatment  of  retroversion  if  there  is  disease  of 


The  Treatment  of  Retroversion 


289 


the  appendages,  pelvic  adhesions,  persistent  prolapse  of  an  ovary 
when  the  uterus  is  replaced,  if  the  woman  is  very  fat  or  has 
reached  middle  age,  if  there  is  a  decided  prolapsus  uteri,  and  if 
the  uterus  is  very  much  heavier  and  larger  than  normal. 

The  patient  is  prepared  for  an  abdominal  section  (page  600). 
The  abdomen  is  opened  in  the  middle  line  by  a  medium-sized  in- 
cision, the  tubes  and  ovaries  are  pulled  out  by  the  fingers  of  the 
left  hand  and  inspected  ;  if  they  are  normal,  the  patient  is  raised  in 
the  Trendelenburg  posture.  A  ligature  of  fine  silk  threaded  on  a 
full-curved  slender  needle  w^ith  a  round  point  is  passed  through  the 
peritoneum  on  the  left  side  from  below  upward,  through  a  few  fibers 
of  the  rectus  muscle  from  above  downward  and  again  through 


Fig.  301. — Groin  wounds  sutured. 


the  peritoneum.  The  uterus  is  seized  between  the  fingers  and 
thumb  of  the  left  hand  and  lifted  out  of  the  abdominal  wound. 
The  needle  is  passed  through  the  fundus  for  a  distance  of  half 
an  inch  at  a  depth  of  a  quarter  of  an  inch  in  the  median  transverse 
line.  The  same  needle  is  then  passed  through  the  peritoneum  and 
some  fibers  of  the  right  rectus  muscle  from  below  upward  ;  lastly, 
through  the  peritoneum  from  above  downward.  A  second  stitch 
is  inserted  in  exactly  the  same  manner  a  quarter  of  an  inch  above 
the  first,  running  through  the  fundus  uteri  slightly  posterior  to  the 
median  transverse  line.  A  gauze  pad  is  passed  into  Douglas's 
pouch  to  clean  out  any  blood  that  may  have  settled  there,  the 
stitches  are  tied  in  a  double  knot,  bringing  the  fundus  in  close 
apposition  with  the  anterior  abdominal  wall,  an  assistant  holding 
19 


290     Displacements  and  Diseases  of  the  Uterus 

two  fingers  behind  the  uterus  while  the  knots  are  tied  to  prevent 
the  inclusion  of  a  loop  of  intestine.  The  patient  is  lowered  to  a 
horizontal  position,  the  gauze  pad  is  removed,  and  the  abdomen  is 
closed  in  the  ordinary  manner  (page  630).  The  object  of  includ- 
ing a  portion  of  the  rectus  muscle  in  the  loop  of  the  uterine 
suture  is  to  secure  a  firmer  hold  and  to  prevent  the  recurrence  of 
the  displacement,  which  is  by  no  means  uncommon  in  the  course 
of  time  or  even  immediately  after  uterine  suspension  if  only  the 


Fig.  302. — Suspension  suture  through  fundus  uteri,  peritoneum,  and  a  part  of  the 

recti  muscles. 


parietal  peritoneum  is  included  in  the  suspension  stitch.  At  the 
same  time  the  fixation  is  not  so  firm  as  to  limit  the  mobility  of 
the  uterus  or  to  interfere  with  subsequent  pregnancies,  the  su- 
tures soon  cutting  through  the  fundus  and  the  adhesions  formed 
between  the  fundus  and  the  parietal  peritoneum  pulling  out  into  a 
suspensory  ligament  an  inch  or  two  long  and  about  as  thick  as  a 
slate-pencil. 

Uterine  suspension  can  be  completed  much  more  quickly  than 
shorteningthe  round  ligaments,  requiringrarelymorethantenor  fif- 


Anteposition,   Anteversion,   and  Anteflexion      291 


teen  minutes  all  told.  The  saving  of  time,  therefore,  might  deter- 
mine one  in  favor  of  this  operation  in  cases  of  multiple  compound 
operations  in  one  individual,  as  curetment,  trachelorrhaphy,  peri- 
neorrhaphy, and  anterior  colporrhaphy,  followed  by  an  operation 
for  retroversion,  especially  if  the  woman's  condition  made  the 
saving  of  time  in  the  whole  operation  a  consideration  of  great 
importance. 

The  operative  treatment  of  retrodisplacement  is  a  matter  of 
election,  as  a  rule,  and  should  be  selected  voluntarily  by  the 
patient.  If,  however,  she  belongs  to  the  working  classes,  it  is 
justifiable  to  advise  it  urgently.  A  pessary  in  a  working-woman 
who  can  not  spare  herself  nor  afford  the  proper  medical  attention 
at  regular  intervals  is  so  unsatisfactory  that  it  can  not  be  recom- 
mended. 

The  results  of  the  operative  treatment  are  usually  most  gratify- 
ing. Local  symptoms  and 
reflex  neuroses  disappear. 
Lines  of  care  which  make 
the  face  haggard  fade  out 
before  the  patient  rises  from 
bed.  The  author  has  seen 
severe  cases  of  epilepsy  of 
some  years'  duration  cured 
by  a  ventrosuspension  of 
the  uterus. 

Anteposition,  Ante= 
version,  and  Anteflexion. 
—  The  uterus  may  be 
pushed  forward  (anteposi- 
tion) by  a  tumor  back  of  it, 
as  an  enterocele,  a  retro- 
uterine hematocele,  an  abscess  in  Douglas's  pouch,  a  fibroid 
tumor,  or  a  very  large  mass  of  feces  in  the  rectum.  The 
symptoms  of  this  displacement  are  dysuria  and  irritability  of 
the  bladder.  The  malposition  of  the  uterus  is  corrected  by  the  re- 
moval of  its  cause.  Anteversion  and  a  moderate  degree  of  ante- 
"flexion  are  the  normal  positions  of  the  uterus.  A  marked  exag- 
geration of  these  positions,  which  is  possible,  may  cause  vesical 
irritability.  Occasionally  one  sees  an  elongated  and  heavy  uterus 
with  the  fundus  lower  and  farther  forward  than  normal,  causing 
discomfort.  A  physiological  example  of  this  displacement  is 
seen  in  early  pregnancy,  and  the  irritable  bladder  which  is  a  con- 
sequence is  a  well-known  sign  of  the  condition.  Exaggerated 
anteflexion  is  not  infrequently  seen.  The  uterus  may  have 
the  shape   of  an   inverted   U-      This   displacement  is   the   result 


sary 


Fig-  303. — Thomas's  anteversion  pes- 
:  A,  Lower  end  resting  just  inside  the 
vaginal  entrance  ;  B,  upper  end  to  be  intro- 
duced in  the  posterior  pouch  of  the  fornix  ; 
C,  anterior,  movable  bow,  which  is  to  lift  the 
uterus  through  the  anterior  pouch  of  the  fornix. 


292      Displacements  and   Diseases  of  the  Uterus 

of  arrested  development  and  is  usually  associated  with  a 
feebly  developed  nervous  system.  The  nervous  phenomena 
that  often  accompany  such  a  displacement — neurasthenia  and 
hysteria — are  not  a  result  of  it.  The  physician,  therefore,  should 
be  on  his  guard  against  directing  his  treatment  to  the  uterus 
for  nervous  symptoms  that  will  not  in  the  least  be  benefited 
by  it  and  may  indeed  be  aggravated  by  frequent  examinations 
and  local  treatment.      Anteflexion  of  the  degree  described  is  a 


Fig.  304. — Dudley's  operation  for  anteflexion.  The  posterior  lip  of  the  cervix  is 
split ;  two  wedge-shaped  excisions  are  made  on  both  sides  of  the  split  cervix.  A 
purse-.string  suture  is  inserted,  pulling  the  os  further  backward  and  straightening  the 
cervical  canal.  A  few  interrupted  sutures  are  required  to  unite  the  lateral  extensions 
of  the  wound. 


common  cause  of  dysmenorrhea  and  sterility,  and  often  requires 
treatment  to  meet  these  indications.  (See  page  386.)  Much 
ingenuity  has  been  devoted  to  the  contrivance  of  mechanical 
devices  to  correct  exaggerated  anterior  displacements.  The 
Thomas  anteversion  pessary,  the  Hewitt  cradle  pessary,  and  the 
sleigh  pessary  of  Schultze  are  the  best  of  their  class  and  are  occa- 
sionally useful,  but  are  not  often  employed  now.  An  intra-uterine 
stem  pessary,  which  would  seem  to  be  the  most  suitable  imple- 


Anteposition,   Anteversion,  and  Anteflexion      293 

ment  for  the  correction  of  anteflexion,  can  not  be  recommended, 
for  the  prolonged  retention  of  any  foreign  body  in  the  uterine 
cavity  predisposes  to  infection  of  the  endometrium  and  to  a 
secondary  infection  and  inflammation  of  the  tubes  and  ovaries. 

It  has  been  proposed  to  make  a  cuneiform  exsection  (cuneo- 
hysterectomy^)  of  the  posterior  uterine  wall  for  anteflexion. 
The  author  has  no  experience  with  the  operation  and  doubts  its 


Fig.  305. — Enormous  elongation  of  supravaginal  portion  of  cervix  and  of  the  isthmus 
uteri.      Internal  measurement  of  uterus,  6  '4  inches. 


justifiability  as  a  routine  procedure,  but  it  is  an  ingenious 
proposition  and  might  on  occasion  be  worth  remembering. 
Dudley's  operation  is  the  best,  in  the  author's  judgment,  for  the 
operative  correction  of  anteflexion  if  anything  more  than  forcible 
dilatation  is  required.      B\^  it  the  cervix  is  drawn  upward  and  the 


^Performed  by  Thirian  in  1892  ;  by  Reed  in  iJ 
cology,"  Reed,  1901. 


See  "Text-Book  of  Gyne- 


294     Displacements  and  Diseases  of  the  Uterus 

OS  is  located  farther  backward,  lessening  the  mechanical  diffi- 
culties of  menstruation  and  of  the  penetration  of  spermatozoa. 

Anterior  displacement  with  fixation  of  the  uterus  by  inflam- 
matory adhesion  may  be  treated  by  tampons  in  the  vagina,  by 
section  of  the  uterosacral  ligaments,  or  by  a  vaginal  or  abdominal 
section  to  free  the  uterus  and  its  appendages  from  adhesions. 

Prolapsus  Uteri. — If  the  cervix  uteri,  not  congenitally  elon- 
gated,   descends   to    or    beyond    the   vulva,    and    its   descent   is 


Fig.  306. — Median  section  of  a  woman  with  complete  prolapse  of  the  uterus  :  a. 
Dilated  left  tube  ;  li,  left  broad  ligament ;  c,  rectum  ;  d,  blood-vessels  ;  e,  anus  ;  f, 
perineum;  g,  prolapsed  posterior  vaginal  wall;  h,  Douglas's  pouch;  i,  uterine 
cavity  ;  k,  fundus  uteri ;  /,  obliterated  cervical  canal  ;  w,  vesico-uterine  pouch  ;  it,  pro- 
lapsed anterior  vaginal  wall ;    0,  urethra  ;  p,  cystocele  (Spiegelberg). 

accompanied  by  some  degree  of  inversion  of  the  vagina,  the 
condition  is  called  prolapse  of  the  uterus.  It  is  customary  to 
draw  a  distinction  between  partial  and  total  prolapse  of  the  uterus, 
the  latter  condition  existing  when  the  whole  uterus  lies  outside 
the  vulva.  There  is  always  some  degree  of  inversion  of  the 
vagina.  The  inversion  of  the  vagina  may  be  complete  while  the 
fundus  uteri  remains  almost  or  quite  at  a  normal  level.  Such  a 
case  is  explained  by  an  enormous  elongation  of  the  lower  uterine 


Prolapsus  Uteri  295 

segment  or  isthmus  uteri  permitting  a  descent  of  the  cervix 
several  inches  outside  the  vulva  while  the  fundus  and  corpus 
uteri  are  held  at  almost  a  normal  level  by  the  uterine  ligaments. 

Owing  to  its  firm  attachment  to  the  cervix,  the  bladder  always 
accompanies  the  descent  of  the  anterior  vaginal  wall,  and  the 
upper  part  of  the  urethra  likewise  follows  the  descent  of  the 
bladder,  so  that  the  urethra  runs  a  curved  course  from  the 
external  meatus  above  to  a  prolapsed  segment  of  the  bladder 
below.  The  bladder  is  divided  practically  into  two  segments,  one 
accompanying  the  prolapse  of  the  anterior  vaginal  wall  and  Ixing 
outside  the  vnh'a,  the  other  remaining  in  the  pelvic  cavity 
(Fig.  306). 

Such  a  mechanical  arrangement  makes  the  complete  evacua- 
tion of  the  bladder  impossible.  The  residual  urine  undergoes 
decomposition,  there  is  cystitis,  and  infection  may  spread  to  the 
kidneys  along  the  ureters,  resulting  possibly  in  a  fatal  pyelitis. 

The  rectum  follows  the  prolapse  of  the  posterior  wall  to  a- 
certain  extent,  but  not  nearly  so  completely  as  the  bladder  does 
that  of  the  anterior  vaginal  wall,  and  perhaps  not  at  all  because 
of  the  loose  connective  tissue  between  the  anterior  wall  of  the 
rectum  and  the  posterior  wall  of  the  vagina,  which  stretches 
readily.  Douglas's  pouch,  however,  is  necessarily  elongated, 
and  beneath  the  inverted  posterior  vaginal  wall  lying  outside  the 
vulva  there  is  commonly  a  segment  of  reduplicated  peritoneum. 
If  the  uterus  lies  completely  outside  the  vulva,  as  it  may,  it  is 
usually  in  a  position  of  retroversion  or  flexion.  In  elderly 
women  with  a  small  atrophied  uterus,  the  position  in  total  pro- 
lapse may  exceptionally  be  one  of  anteversion.  The  prolapsed 
uterus  is  usually  much  enlarged,  especially  the  cervix,  which  is 
often  enormously  broad.  If  the  fundus  uteri  remains  in  the  pelvic 
cavity  the  uterus  is  much  lengthened.  A  measurement  of  six  or 
more  inches  b\"  the  sound  is  not  uncommon.  The  increase 
in  breadth  is  due  mainly  to  edema;  that  in  length,  to  stretching. 
When  the  uterus  is  replaced  and  held  in  place  by  tampons,  its  size 
rapidly  diminishes. 

Etiology.— In  accounting  for  prolapse  one  must  differentiate 
the  commoner  cases  following  childbirth  from  those  that  occur 
in  nulliparous  women.  The  explanation  for  prolapse  in  women 
who  have  borne  children  is  found  in  a  combination  of  ph}'sical 
conditions  and  in  the  woman's  mode  of  life.  There  has  been  an 
injury  of  the  muscle  of  the  urogenital  trigonum  and  a  detachment 
of  the  anterior  vaginal  wall  from  its  subjacent  attachments.  The 
prolapse  of  the  anterior  wallwhich  follows  drags  upon  the  cervix, 
pulls  it  forward  and  downward,  and  produces  a  retroversion 
of  the  uterus  if  such  a  malposition  did   not  already  exist.      The 


296     Displacements  and  Diseases  of  the  Uterus 

retroversion  brings  the  long  axis  of  the  uterus  in  coincidence 
with  the  long  axis  of  the  vaginal  canal  and  renders  the  descent 
of  the  former  along  the  latter  easy'.  There  has  also  been  an 
injury  of  the  pelvic  floor,  a  laceration  of  the  levator  ani  muscle, 
resulting  in  a  prolapse  of  the  posterior  vaginal  wall,  which  pulls 
upon  the  posterior  lip  of  the  cervix,  dragging  it  downward,  help- 
ing to  tilt  the  fundus  over  backward,  and  assisting  in  the  descent 
of  the  cervix.  The  woman  almost  always  belongs  to  the  work- 
ing classes.  Her  laborious  life,  with  hard  work  for  hours  at  a 
time  on  her  feet,  increases  the  intra-abdominal  pressure  and  in 
time  drives  the  uterus  out  of  the  pelvis  in  the  direction  of  least 
resistance  along  the  relaxed  vagina,  until  the  latter  is  partially  or 
entirely  inverted.  The  retroverted  and  particularly  the  partially 
prolapsed  uterus  becomes  congested,  edematous,  and  heavy.  Its 
increased  weight  helps  its  descent.  The  middle-aged  or  elderly 
woman  usually  stoops  ;  the  inclination  or  obliquity  of  the  pelvis 
is  decreased  ;  hence  the  abdominal  contents  press  more  directly 
upon  the  pelvic  viscera.  The  degree  to  which  the  whole 
uterus  descends  depends  entirely  upon  the  strength  of  the 
uterine  ligaments,  particularly  the  cardinal  and  the  uterosacral 
ligaments.  If  they  are  weakened  by  the  muscular  atrophy 
of  middle  and  advanced  age,  in  which  prolapse  usually  occurs, 
and  by  the  absorption  of  the  pelvic  fat,  and  if  they  stretch  inor- 
dinately under  the  extra  strain  imposed  upon  them,  the  whole 
uterus  descends  and  may  protrude  in  its  entire  length  outside  the 
vulva.  If  the  ligaments  resist  the  descent  of  the  uterus,  the 
complete  inversion  of  the  vagina  is  still  possible,  dragging  the 
cervix  outside  the  vulva  the  full  length  of  the  vaginal  walls,  while 
the  fundus  remains  well  within  the  pelvic  cavity.  Such  a  result 
is  rendered  possible  by  the  elasticity  of  the  lower  uterine  segment, 
which  stretches  to  an  extraordinary  extent  in  order  to  allow  the 
protrusion  of  the  cervix  from  the  vulva.  This  variety  of  prolapse, 
which  is  commoner  than  the  total  prolapse  of  the  uterus,  was 
formerly  ascribed  to  a  "  supravaginal  elongation  of  the  cervix." 
It  is  not,  however,  the  cervix  alone,  but,  as  already  stated,  mainly 
the  lower  uterine  segment  which  is  elongated.  A  complete  in- 
version of  the  vagina  has  followed  a  firm  ventrofixation  of  the 
uterus.  The  fundus  remaining  attached  to  the  abdominal  wall, 
the  cervix  has  protruded  from  the  vulva  almost  the  entire  length 
of  the  vagina. 

It  is  more  difficult  to  explain  prolapsus  uteri  in  nulliparous 
women.  The  condition  may  be  congenital,  but  such  cases  are 
very  rare.  It  may  develop  in  young  women,  although  it  is  more 
commonly  observed  at  and  after  the  menopause.  The  author 
has   seen    two    cases    of  total    prolapse    in   young  girls    which 


Prolapsus   Uteri 


297 


were  apparently  due  to  premature  and  excessive  sexual  inter- 
course. One  of  these  patients  was  seventeen  years  old.  She 
had  been  a  prostitute  since  the  age  of  eleven.  The  vaginal  walls 
had  been  overstretched,  their  attachments  weakened  or  injured, 
and  there  had  probablx'  been  a  retroversion  of  the  uterus  with  an 
increase  of  intra-abdominal  pressure. 

In  elderly  women  there  is  probably  a  combination  of  retro- 
version, weakening  of  the  uterine  ligaments,  and  increased  intra- 
abdominal pressure.  In  one  of  the  author's  cases  there  had  been 
a  violent  and  almost  incessant  asthmatic  cough  for  years. 


Fig.   307. — Partial  prolapse  of  the  uterus. 


Finally,  one  must  always  think  of  the  possibility  of  an  intra- 
pelvic  or  of  an  intra-abdominal  tumor  or  of  ascites  forcing  the 
uterus  out  of  tlie  pelvis  in  the  direction  of  least  resistance. 

Clinical  History,  Symptoms,  and  Diagnosis. — -The  woman  is 
usually  of  the  working  class.  Prolapsus  uteri  is  a  disease  of 
the  poor,  not  of  the  well-to-do.  She  has  usually  borne  chil- 
dren and  is  of  middle  age,  although  prolapse  is  possible  in  nullip- 
arous  women  and  in  young  girls.  The  patient  ordinarily  gives 
the  history  of  a  precedent  retroversion,  rectocele,  and  cystocele. 


298      Displacements  and  Diseases  of  the  Uterus 

The  actual  protrusion  of  the  uterus  often  occurs  suddenly  in  con- 
sequence of  some  exertion,  and  may  be  the  first  symptom  to 
attract  the  patient's  attention.  After  the  prolapse  is  evident  to 
the  patient,  if  not  before,  she  suffers  from  dysuria  and  irritable 
bladder;  backache  and  bearing  down  ;  difficult  locomotion  and 
a  constant  irritation  of  the  protruding  mass  and  usually  of  the 
inner  thighs,  which  are  moistened  with  the  urine  that  flows  over 
them  and  are  irritated  by  the  urinary  salts  that  accumulate  upon 


Fig.  308. — Complete  inversion  of  the  vagina  and  prolapse  of  the  cervix  in  a  pregnant 

woman. 


them.  A  disagreeable  odor  is  noticed  on  account  of  the  difficulty 
of  keeping  the  parts  clean.  A  constant  discharge  is  often  com- 
plained of  due  to  a  weeping  from  the  cervical  canal  and  uterine 
cavity,  the  result  of  edema,  of  a  hyperplastic  endometritis,  and  of 
ulcerations  around  the  cervix.  There  may  also  be  the  dribbling 
urine  of  an  overfilled  bladder,  the  paradoxical  incontinence  of 
retention. 


Fig.   309. — Prolapse  of  the  uterus  with  bilateral  laceration  of  the  cervix. 


Fig.  310. — Complete  inversion  of  the  vagina  ;  prolapse  of  the  cervix,  which  is  hyper- 

trophied  and  eroded. 
299 


300     Displacements  and  Diseases  of  the  Uterus 

If  the  patient  is  examined  in  the  dorsal  position,  the  full 
degree  of  prolapse  which  is  present  in  the  erect  posture  may  not 
be  appreciated.  Cases  apparently  of  partial  prolapse,  therefore, 
should  always  be  examined  in  the  erect  posture.  Commonly,  if 
the  prolapse  is  complete,  there  is  no  mistaking  it  in  any  posture 
(Figs.  310,  312).  A  huge  cylindrical  mass  protrudes  from  the 
vulva  ;   the  vagina  is  obviously  completely  inverted  ;  the  external 


Fig.    311. — Partial  prolapse  of  the  uterus  with  hypertrophied  and  lacerated  cervix. 


OS  uteri  is  evident ;  the  prolapsed  segment  of  the  bladder  gives 
a  peculiar  fullness  to  the  anterior  vaginal  wall,  and  something  of 
the  same  sort  is  often  noticed  on  the  upper  portion  of  the  posterior 
vaginal  wall,  where  there  may  be  a  rectocele  or  a  bulging  of  the 
prolapsed  reduplication  of  the  peritoneum.  Around  the  cervix 
there  is  often  ulceration  due  to  defectiv^e  nutrition  from  the  inter- 
ference with  the  circulation.  The  vaginal  mucous  membrane 
is  usually  much  thickened,  dry  and  harsh  in  feel.  It  may  be 
possible  to  palpate  the  whole  of  the  uterus  outside  the  vulva 
through   the   inverted   vaginal    walls.      If  a   part   of  the    uterus- 


Fig.   312. — Total  prolapse  of  the  uterus. 


Fig.   313. — Prolapse  of  uterus  and  detachment  of  posterior  vaginal  wall. 

301 


Fig.   314. — Partial  prolapse  of  the  uterus  in  a  virgin,  with  intact  hymen. 


Fig.   315. — Total  prolapse  in  a  nulliparous  woman. 
302 


Prolapsus  Uteri 


303 


remains  within  the  pelvis,  this  fact  and  the  position  of  the  fundus 
are  demonstrated  by  a  recto-abdominal  examination.  While 
total  prolapse  may  be  diagnosticated  at  a  glance,  a  bimanual  ex- 
amination of  the  pelvic  contents  should  never  be  neglected,  for 
occasionally  the  uterus  is  forced  out  of  the  pelvis  by  a  tumor  or 
by  ascites,  which  might  not  be  recognized  until  the  operation  for 
simple,  uncomplicated  prolapse  were  undertaken.^ 

It  is  usually  better  to  reduce  the  prolapse  and  to  examine 
the  pelvic  organs  by  a  combined  vaginal-abdominal  examination. 

Prolapsus  uteri  of  itself  is  rarely  fatal.      The  author  has  seen 
two  cases  of  strangulation  of  a  prolapsed  uterus,  gangrene  of  the 
uterus  and  fatal  peritonitis.      In  one  a  hysterectomy  was   imme- 
diately  performed   without   avail ;  the  other 
woman  was  moribund  when  she  was  brought 
to  the  hospital. 

Treatment. — The  iirst  object  of  treatment 
is  to  reduce  the  prolapse.  This  is  usually 
easy.  Seizing  the  uterus  between  the  thumb 
and  fingers,  steady  pressure  is  made  in  the 
axis  of  the  vaginal  canal,  whereupon  the 
uterus  and  the  inverted  vagina  return  within 
the  pelvis.  The  patient  should  then  be  put 
in  the  knee-chest  posture  and  with  the  aid 
of  a  Sims'  speculum  the  vagina  is  packed 
with  wool  tampons  saturated  with  boroglyc- 
erid,  which  are  allowed  to  remain  in  place 
forty-eight  hours.  If  possible,  the  patient 
should  be  confined  to  bed  for  a  few  days 
in  order  that  the  congestion  and  edema  of 
the  uterus  shall  be  reduced  as  rapidly  as 
possible.  Occasionally  it  may  be  difficult  to 
return  the  prolapsed  uterus  within  the  pelvis, 

on  account  of  its  edema  and  enlargement.  It  may  be  necessary 
to  elevate  the  foot  of  the  bed  in  which  the  woman  lies,  to  apply 
ice -water  and  glycerin  compresses  to  the  uterus,  and  even  to 
resort  to  multiple  punctures  of  the  cervix  or  local  bloodletting, 
before  the  uterus  can  be  replaced.  Smearing  the  vaginal  walls 
with  an  unguent  before  attempting  reduction  by  taxis  is  of 
advantage.  Having  reduced  the  prolapse,  the  physician  must 
decide  upon  the  subsequent  treatment  of  the  case,  Avhether  he  shall 
advise    radical    cure    by  operation  or    the  use  of  a  mechanical 

^  The  author  once  made  this  mistake  through  carelessness.  His  chief  of  dis- 
pensary called  his  attention  to  a  case  of  prolapse  which  was  obvious  at  a  glance. 
The  woman  was  admitted  to  the  hospital  for  operation.  Brought  into  the  operating 
room  in  her  turn  the  following  day,  a  large  abdominal  tumor  was  discovered  which 
proved  later  to  be  cancerous. 


.    316. — Globe  pes- 
sary with  stem. 


304     Displacements  and  Diseases  of  the  Uterus 

support.  The  former  is  mucli  the  more  satisfactory  treatment 
and  is  as  a  rule  to  be  recommended,  but  it  may  be  impracti- 
cable in  individual  instances  because  of  the  patient's  age,  her 
general  condition,  or  because  she  refuses  operation.  Hence 
it  is  occasionally  necessary  to  employ  a  mechanical  support. 
Many  different  pessaries  for  a  prolapsed  uterus  have  been  devised, 
but  the  author  has  for  some  years  employed  but  two,  a  mod- 
erate-sized globe  pessary  on  a  stem  supported  by  an  abdominal 
belt  and  rubber  tubing,  or  the  Goddard  pessary.  The  latter  is 
more  suitable  for  unintelligent  women  of  the  poorer  classes.  The 
efficiency  of  a  support  modeled  on  a  globe  pessary  is  often  in- 
stinctively recognized  by  the  patient  herself  One  of  the  author's 
patients  every  day  inserted  a  wad  of  newspaper  rolled  into  a  ball  ; 
two  others  inserted  a  fresh  apple  into  the  vagina  every  morning. 
They  had  thus  made  themselves  fairly  comfortable  for  years. 
If  an  operation   is   determined   upon,  as  it  should   be,  unless 

there  is  good  reason 
against  it,  the  phys- 
ician must  decide 
whether  to  trust  to 
a  plastic  operation 
alone  or  whether 
the  plastic  operation 
should  be  reinforced 
by  suspending  the 
uterus  to  the  abdom- 

Fig-  317- — Goddard  pessary.  iual    wall.       The   fol- 

lowing considera- 
tions should  govern  his  choice  :  Prolapse  in  nulliparous  women 
can  not  be  cured  by  a  plastic  operation  alone  ;  the  suspension  of 
the  uterus  in  addition  is  necessary.  If  the  woman  is  of  child- 
bearing  age  and  is  living  with  her  husband,  so  that  an  extreme 
narrowing  of  the  vagina  is  inadvisable,  the  suspension  of  the 
uterus  should  be  added  to  the  plastic  operation.  If  there  is 
complete  inversion  of  the  vagina  with  the  prolapse  of  the  cervix 
by  the  so-called  supravaginal  elongation  while  the  uterine  fundus 
remains  at  a  good  level  in  the  pelvis,  a  plastic  operation  alone 
is  often  sufficient.  If  the  woman  is  at  or  past  the  menopause  and 
coitus  need  not  be  considered,  a  plastic  operation  with  exaggerated 
narrowing  of  the  vagina  will  probably  suffice. 

This  important  point  being  decided,  the  form  of  plastic  opera- 
tion to  be  undertaken  must  be  settled.  Individual  judgment 
naturally  differs  on  this  question.  For  years  the  author  has  de- 
pended with  uniform  success  in  suitable  cases  upon  an  extensive  Mar- 
tin's anterior  colporrhaphy  with  the  tier  suture  of  catgut,  a  high 


Pro! 


apsus 


Ute 


n 


305 


Hegar's  amputation  of  the  cervix  and  a  very  extensive  Hegar's 
operation  upon  the  posterior  vaginal  wall,  the  apex  of  the  denuda- 
tion reaching  almost  to  the  cervix  and  its  base  being  as  broad  as 
possible.  These  operations  are  described  elsewhere.  It  is  only 
necessary  here  to  call  attention  to  certain  essentials  in  the  tech- 
nic  of  their  combination.  The  cervix  is  seized  with  a  double 
tenaculum  and  dragged  forcibly  outward ;  the  area  to  be  denuded 
on  the  anterior  vaginal  wall  is  marked  out  by  an  oval  incision 
with  a  sharp  knife.  The  circular  incision  for  the  cervical  ampu- 
tation is  then  made,  and  the  cervix  is  partly  freed  by  dissection  of 


Fig.  318. 


-Incisions  for  the  anterior  colporrhaphy  and  amputation  of  the  cervix  for 
prolapse. 


the  vaginal  mucous  membrane  upward.  The  denudation  of  the 
anterior  wall  is  completed  by  dissecting  off  the  oval  flap  in  one 
piece  by  a  knife ;  the  amputation  of  the  cervix  at  the  level  of  the 
internal  os  is  completed,  including  the  insertion  and  knotting  of 
the  catgut  sutures;  double  tenacula  seize  the  stump  of  the  cervix 
and  pull  it  down;  the  tier  suture  is  inserted  in  the  anterior  vaginal 
wall,  beginning  just  below  the  urethral  orifice;  if  there  is  tension 
on  the  last  tier  of  the  running  suture,  the  cervix  is  released 
and  the  uterus  is  pushed  up  into  the  pelvis,  whereupon  it  is  easy 


3o6      Displacements  and   Diseases  of  the  Uterus 

to  bring  the  edges  of  the  mucous  membrane  of  the  anterior 
vaginal  wall  together.  The  cervical  amputation  and  anterior 
colporrhaphy  being  completed,  the  uterus  pushed  up  to  its 
normal  level  in  the  pelvis,  the  posterior  colporrhaphy  by 
Hegar's  method  is  performed.  The  sutures  in  the  upper 
part  of  this  wound  may  be  of  catgut;  the  lower  sutures  and 
those  in  the  perineum  should  be  of  silkworm-gut,  shotted. 

European  statistics  show  discouraging  results  in  the  operative  treatment  of  pro- 
lapsus uteri.  On  the  average  ultimate  failure  is  reported  in  about  30  per  cent,  of  the 
cases.  This  is  certainly  not  the  author's  experience.  The  operations  above  de- 
scribed have  been  performed  frequently  as  routine  work  in  his  hospital  services  for 
more  than  fifteen  years.  The  patients  have  numbered  considerably  more  than  100. 
Not  one  of  them  has  reapplied  on  account  of  a  recurrence.  Naturally,  some  of  them, 
in  case  of  failure,  would  apply  to  other  clinics  ;  but  if  the  proportion  had  been  as  large  as 
a  third,  a  few  at  least  would  have  reappeared.  The  ill  success  of  the  operative  treat- 
ment of  prolapse  on  the  continent  of  Europe  may  be  explained,  perhaps,  by  the  hard 
manual  labor  performed  by  women  of  the  peasant  and  laboring  classes.  In  conse- 
quence of  this  ill  success  many  radical  and  some  bizarre  procedures  have  been  adopted. 
The  uterus  has  been  turned  out  of  the  anterior  vaginal  vault  by  anterior  colpotomy 
and  sewed  in  the  vagina,  upside  down,  to  the  anterior  vaginal  wall  ;  or  sewed  to 
both  anterior  and  posterior  walls,  an  artificial  os  being  made  in  the  fundus  (Wert- 
heim,  W.  A.  Freund).  The  anterior  vaginal  wall  has  been  suspended  to  the  retro- 
symphyseal  connective  tissue.  The  uterosacral  and  the  infundibulopelvic  ligaments 
have  been  shortened.  The  bladder  has  been  suspended  to  the  pelvic  connective  tis- 
sue. Douglas's  pouch  has  been  partially  or  wholly  obliterated.  Vaselin  has  been 
injected  under  the  anterior  vaginal  wall,  and  quinin  solution  into  the  parametrium,  to 
produce  a  cellulitis!  Finally,  the  uterus  and  the  whole  vagina  have  been  exsected. 
The  proportion  of  permanent  cures  has  not  been  increased  by  these  procedures,  ex- 
cept by  the  last,  which,  however,  is  scarcely  ever  justifiable.  ^ 

Inversion  of  the  uterus  is  a  displacement  in  which  the 
uterus  is  partially  or  completely  turned  inside  out.  The  cervix 
is  almost  always  unaffected  by  the  inversion,  forming  a  collar 
around  the  isthmus  of  the  inverted  corpus  and  opposing  by  the 
contraction  of  its  circular  fibers  the  reposition  of  the  bulky  cor- 
pus and  fundus  through  its  contracted  ring.  Inversion  of  the 
uterus  is  very  rare.  Many  experienced  gynecologists  have  never 
seen  a  case. 

Etiology. — Inversion  of  the  uterus  occurs  in  labor  during  or 
after  the  third  stage,  or  is  the  result  of  a  polypoid  tumor  depend- 
ing from  the  fundus.  In  the  latter  case  the  weight  of  the  tumor 
depresses  the  fundus,  and  the  contraction  of'  the  uterine  muscle 
in  efforts  to  expel  the  tumor  increases  the  traction  on  the  fundus, 
until  it  is  inverted. 

Symptoms  and  Diagnosis. — If  an  inversion  originating  in  child- 
birth is  not  corrected,  the  symptoms  after  the  completion  of 
puerperal  involution  are  metrorrhagia,  leukorrhea,  backache, 
a  sense  of  drag  and  bearing  down  in  the  pelvis,  and  inability  to 

^  Baumm,  "Arch.  f.  Gyn.,"  P>d.  Ixv,  11.  2.  Bucura,  "  Zeitschr.  f.  Geburtsh.," 
xlv,  3.  II.  W.  Freund,  "  Centralbl.  f.  Gyn.,"  No.  18,  1901.  Stone,  "Amer.  Jour, 
of  Obstet.,"  1901,  p.  675. 


Inversion  of  the  Uterus  307 

remain  long  or  to  make  exertion  in  the  erect  posture.  On  ex- 
amination three  degrees  of  inversion  may  be  discovered  :  in  the 
first,  the  fundus  remains  witliin  the  cervical  canal  ;  in  the  second 
it  protrudes  into  the  vagina  and  the  corpus  may  be  completely 
inverted,  although  if  involution  is  normally  completed  the  fundus 
may  not  descend  much  more  than  an  inch  below  the  external 
OS  ;  in  the  third  degree  prolapsus  is  associated  with  inversion  and 
the  inverted  uterus  hangs  outside  the  vulva. 

On  a  bimanual  examination,  especially  a  recto-abdominal  ex- 
amination, the  absence  of  the  uterine  body  from  its  normal  situ- 
ation is  noted  and  a  cup-shaped  orifice  or  a  slit  is  felt  at  the 
upper  margin  of  the  cervix,  into  which  the  uterine  appendages 
may  be  prolapsed.  A  finger  or  a  sound,  if  inserted  past  the 
projecting  fundus  into  the  external  os,  only  enters  the  depth  of 
the  cervical  canal,  about  two  centimeters. 

The  condition  which  may  be  and  has  been  most  often  mistaken 
for  inversion  is  a  polypoid  tumor  protruding  from  the  external  os, 
but  the  differential  diagnosis  should  not  present  insuperable  diffi- 
culties. The  uterine  cavity  has  a  normal  or  increased  depth,  a 
bimanual  examination  demonstrates  the  uterine  body  in  its  normal 
situation,  and  by  traction  on  the  polyp  its  attachment  to  the  cervix 
or  uterine  wall  by  a  pedicle  may  be  determined.  A  uterine  polyp  is, 
moreover,  usually  very  much  firmer  or  very  much  softer  than  the 
uterus  itself,  as  it  is  fibrous  or  mucous.  A  cystic  polyp,  giving  the 
sensation  of  a  hollow  tumor,  may,  however,  feel  much  like  the  uter- 
ine body.  Occasionally  the  cervical  canal  is  obliterated  by  adhe- 
sions between  the  endometrium  and  the  periphery  of  a  polyp.  Even 
in  such  a  case,  although  it  is  impossible  to  demonstrate  the  ex- 
istence of  a  uterine  cavit}',  a  bimanual  examination  detects  the 
uterine  body  where  it  should  be.  If  the  inversion  is  caused  by  a 
tumor  attached  to  the  fundus,  there  are  all  the  signs  of  the  in- 
version, and  the  origin  of  the  tumor  from  the  fundal  endometrium 
is  in  plain  sight  if  the  former  is  pulled  upon  and  the  inverted 
fundus  is  brought  outside  the  vulva.  The  feel  and  the  appear- 
ance of  the  tumor,  moreover,  present  a  sharp  contrast  with  the 
uterus,  especially  if  the  former,  as  is  often  the  case,  has  partially 
sloughed  from  a  deficient  blood-supply  due  to  the  compression 
of  the  vaginal  walls  and  to  the  displacement  of  the  uterus. 

Treatment. — In  no  other  disease  of  women  is  there  such  a 
diversity  of  opinion  as  to  the  proper  treatment.  The  primary 
object  of  all  the  numerous  measures  advocated  is,  of  course,  the 
reinversion  of  the  uterus.  This  may  be  accomplished  in  three 
ways  :  by  taxis,  by  long-continued  pressure,  and  by  operative 
treatment. 

Tlie  Reduction   of  Inversion  by  Taxis. — This  method  should 


J 


08      Displacements  and  Diseases  of  the  Uterus 


always  be  adopted  as  soon  as  the  inversion  is  recognized  after 
labor,  and  if  resorted  to  without  too  much  delay  should  always 
be  successful.  It  may  become  impracticable  if  the  cervix  is  al- 
lowed to  recover  its  contractile  power  after  labor.  If  weeks, 
months,  or  years  have  elapsed  since  the  inversion,  attempts  at 
taxis  are  likely  to  fail,  but  should  always  be  made  under  anes- 
thesia before  resorting  to  other  plans  of  treatment.  Excessive 
force  and  injudicious  persistence,  however,  may  perforate  the 
uterus  or  so  bruise  it  that  sloughing  results.  In  either  case  there 
may  be  a  fatal  result.  The  following  plans  of  applying  taxis 
have  been  successful:  (i)  Inserting  the  whole  hand  into  the 
vaeina.  surroundins:  the  isthmus  uteri  within  the  cervix  with 
the  fingers  and  thumb,  making  pressure  upon  the  fundus  with 
the  palm  of  the  hand,  and  counterpressure  upon  the  cervical 
ring  above  through  the  abdominal  walls  (Emmet).  (2)  Placing 
the  thumb  and  middle  finger  against  the  uterine  horns,  making 
pressure  first  upon  one  and  then  upon  the  other,  and,  after  reinvert- 
ing  the  horns,  replacing  the  fundus,  counterpressure  being  made 
upon  the  cervix  from  above  (Noeggerath).  (3)  Making  pressure 
with  the  finger-tips  of  one  hand  against  the  lateral  wall  of  the 
lower  uterine  segment  in  a  direction  forward  and  upward  while 
an  assistant  with  both  hands  presses  upon  the  cervical  ring  from 
above  and  endeavors  to  dilate  it  by  traction  in  opposed  directions 
through  the  abdominal  walls.  The  author  has  reduced  five  cases 
of  inversion  in  this  manner.  (4)  Inserting  two  fingers  into  the 
rectum  and  making  traction  upon  the  cervical  ring,  while  pres- 
sure is  applied  with  the  other  hand  to  the  fundus  (Courty).  (5) 
Inserting  two  fingers  in  the  rectum,  the  forefinger  of  the  other 
hand  in  the  bladder  through  a  dilated  urethra,  making  traction 
upon  the  cervical  ring,  while  the  two  thumbs  press  upon  the 
uterine  fundus  (Tate,  of  Cincinnati). 

T/ic    Treatment  of  Inversion    by  Long-continued  Pressure. — 
Various   plans   have  been   devised   to   exert  pressure    upon   the 
fundus  for   hours   and    days,  thus   gradually  replacing   it.      Col- 
peurynters  distended  with  water  and  air  have  had  their  advocates. 
This  method,  when  it  succeeds  at  all,  requires  at  least  a  week, 
perhaps  a  month  ;  the  patient  experiences   great   pain,  and  can 
not  endure  the  pressure  for  more  than  five  or  six  hours  at  a  time. 
There  is  likely  to  be  high  fever,  and  there  may  be  fatal  infection. 
Repeated  packings  with  iodoform  or  sterile  gauze  are  not  so  ob- 
jectionable, but  do  not  often  succeed.   White,  Aveling,  and  others 
have  used  curved  and  S-shaped  rods  with  a  cap  at  the  inner  end 
to  press  upon  the  fundus  while  elastic  pressure  was  applied  from 
without  by  various  devices,  such  as  rubber  bands  fastened  to  an 
abdominal  belt  and  a  spiral  spring  supported  by  a  T-binder.      A 


Inversion  of  the  Uterus  309 

stethoscope  has  been  employed  with  the  cup  against  the  fundus 
and  ligatures  passed  through  the  cervix  and  drawn  taut  through 
the  earpiece.  If  the  fundus  is  partially  reduced,  Emmet's  propo- 
sition to  close  the  cervix  over  it  with  wire  sutures  may  be  worth 
remembering.  The  steady  traction  on  the  cervix  and  the  pres- 
sure on  the  fundus  may  complete  the  reduction  of  the  displace- 
ment. Success  has  been  achieved  with  all  these  appliances,  but 
it  is  always  problematical  and  none  of  them  is  free  from  danger. 

Tlic  Operative  Treatme^it  of  Inversion. — The  following  plans 
have  been  proposed  for  the  correction  of  an  inversion  by  opera- 
tion :  Discission  of  the  cervix ;  abdominal  section,  dilatation  of 
the  cervacal  ring  from  above,  and  reposition  of  the  fundus  by  direct 
traction  upon  it ;  median  posterior  hysterotomy,  dilatation  of  the 
cervical  ring  through  the  incision,  closure  of  the  wound,  and  re- 
position of  the  uterus  or  repair  of  the  uterine  wound  after  reposi- 
tion by  posterior  colpotomy ;  median  complete  division  of  the 
cervix  and  uterine  wall  to  the  fundus  either  anterior  or  posterior, 
with  colpotomy  to  permit  the  repair  of  the  uterine  wound  after 
reposition;  vaginal  hysterectomy.^ 

Of  these  operations,  discission  of  the  cervix  is  the  least  for- 
midable and  should  often  succeed.  The  cervix  is  cut  in  two  to 
or  through  the  peritoneum  in  the  median  line  posteriorly  ;  taxis 
is  employed,  and  after  the  reposition  of  the  uterus  the  cervical 
wound  is  closed  by  interrupted  sutures  of  silkworm-gut,  the 
higher  sutures  shotted  in  the  posterior  vaginal  vault,  the  lower 
upon  the  vaginal  portion  of  the  cervix.  The  author  has  thus  re- 
duced a  complete  inversion  of  the  uterus  of  three  months'  dura- 
tion that  had  resisted  taxis  at  the  hands  of  three  gynecologists  on 
different  occasions.  If  the  complete  division  of  the  cervix  is  in- 
sufficient, the  incision  is  carried  through  the  uterine  wall  also,  an 
effort  to  reduce  the  displacement  by  taxis  being  made  with  each 
extension  of  the  incision,  which  need  scarcely  ever,  in  the  author's 
judgment,  be  carried  to  the  fundus.  After  reposition  the  uterine 
wound  must  be  united  through  the  incision  of  a  posterior  trans- 
verse colpotomy  in  the  vaginal  vault,  the  uterine  muscle  being 
joined  by  a  tier  suture  of  catgut,  the  peritoneum  by  close-set  in- 
terrupted sutures.  The  cervix  may  be  united  by  an  extension  of 
the  uterine  suture  or  by  separate  interrupted  sutures.  If  there 
is  no  oozing  to  speak  of  after  the  closure  of  the  uterine  wound, 
the  vaginal  wound  may  be  closed;  otherwise  drainage  must  be 
provided  by  a  strip  of  gauze  in  Douglas's  pouch,  removed  in 
forty-eight  hours,  and  replaced,  if  the  discharge  continues,  by  a 
T-shaped  rubber  drainage-tube.      Division  of  the  cervix   and  of 

1  A  complete  bibliography  of  the  operative  treatment  of  inversion  may  be  found 
in  the  article  by  Oui,  in  the  "Annates  de  Gyn.  et  d'Obstet.,"  Oct.  and  Nov.,  1901. 


3IO     Displacements  and   Diseases  of  the  Uterus 

the  uterus  in  the  anterior  median  line  after  separating  the  cervix 
from  the  bladder  has  the  advantages  that  adhesions  along  the 
line  of  the  wound  do  not  predispose  to  retrodisplacement  of  the 
uterus,  and  that  an  anterior  T-shaped  colpotomy  makes  the  uter- 
ine wound  more  accessible  for  suturing,  but  there  is  a  chance  of 
injury  to  the  bladder  and  drainage  is  not  so  easily  secured. 

Hysterotomy  and  dilatation  of  the  cervical  ring  through  the 
incision  has  no  apparent  advantages  over  the  method  just  de- 
scribed, is  less  certain  to  succeed,  and  is  more  difficult  and 
tedious.  Abdominal  section,  dilatation  of  the  cervical  ring  from 
above,  and  traction  upon  the  fundus,  has  a  high  proportion  of 
failures  and  mortality.  Hysterectomy  should  scarcely  ever  be 
required.  Pregnancy  has  followed  the  reduction  of  an  inversion 
of  eleven  years'  standing.  The  needless  mutilation,  therefore, 
of  a  Avoman  of  child-bearing  age  should  be  condemned.  In  the 
treatment  of  inversion  caused  by  a  polyp  the  tumor  should  first 
be  removed  by  dissecting  its  base  off  the  fundus  uteri  or  by  avul- 
sion. The  uterus  should  then  be  replaced  by  taxis,  if  possible  ; 
if  not,  one  of  the  other  plans  of  treatment  described  may  be 
adopted.  The  tumor  which  has  caused  the  inversion  has  not 
infrequently  undergone  some  degree  of  gangrene;  the  w^ound 
left  by  its  removal,  therefore,  should  be  cauterized  with  pure  car- 
bolic acid,  and  after  reposition  there  should  be  for  a  week  a  daily 
irrigation  of  the  uterine  cavity  with  sterile  water. 

Metritis. — An  inflammation  of  the  myometrium  is  called 
metritis;  that  of  the  endometrium,  endometritis;  that  of  the 
perimetrium,  perimetritis.  The  present  section  deals,  therefore, 
with  an  inflammation,  acute  or  chronic,  of  the  myometrium, 
although  it  must  be  understood  that  metritis  and  endometritis 
are  inseparable,  one  perhaps  antedating  and  causing  the  other, 
but  both  in  time  coexisting. 

Acute  Metritis. — An  acute  inflammation  of  the  myometrium 
is  most  often  the  result  of  an  infection  of  the  endometrium  and  is 
most  frequently  seen  after  childbirth.  ^  It  may  follow  the  in- 
troduction of  instruments  in  the  uterine  cavity,  especially  if  the 
technic  is  faulty  in  asepsis  ;  operations  upon  the  cervix ;  injuries 
to  the  uterine  walls,  exposure  to  cold,  overexertion  and  coitus 
during  menstruation,  or  it  may  occur  in  the  course  of  infectious 
fevers,  as  the  result  of  syphilis  and  phosphorus-poisoning,  and 
in  a  gonococcus  infection  of  the  myometrium.  The  symptoms 
are  great  tenderness  on  pressure  over  the  uterus,  tympany, 
painful  uterine  cramps,  fever,  suppression  of  the  menses  or 
metrorrhagia,  and  possibly  a  profuse  purulent  uterine  leukor- 
rhea.     On  examination  the  cervix  is  soft  and   enlarged,  as  is  the 

'  Puerperal  metritis  is  not  considered  in  this  work. 


Chronic  Metritis  31 1 

uterine  body,  and  any  mo\'ement  or  compression  of  the  uterus  in 
a  bimanual  examination  is  ver\'  painful. 

The  treatment  is  rest  in  bed,  the  ice-water  coil  or  an  ice-bag 
over  the  uterus,  lukewarm  vaginal  douches  twice  daily,  laxa- 
tives, and  moderate  doses  of  opiates  or  heroin  for  the  pain.  In 
the  gonorrheal  variety  and  in  the  inflammation  following  acute 
infectious  endometritis,  an  intra-uterine  douche,  at  least  once  a 
day,  of  permanganate  of  potassium  solution  (a  dram  of  the 
saturated  solution  to  the  quart),  is  an  essential  part  of  the  treat- 
ment. In  the  acute  metritis  occasionally  seen  with  suppression 
of  menses  due  to  cold,  a  hot- water  bag  over  the  uterus  should 
be  substituted  for  the  ice  applications.  After  the  acutest  stage  is 
passed,  iodin  over  the  hypogastrium  and  on  the  vaginal  vaults 
hastens  the  cure.  The  prognosis  is  favorable  except  in  puerperal 
cases  and  in  very  severe  infections  following  operations  upon  or 
injuries  to  the  uterus,  which  may  demand  hysterectomy.  The 
disease  may  run  a  course  of  two  to  four  weeks. 

Chronic  Metritis  is  a  common  disease  of  women.  It  follows 
any  condition  imposing  upon  the  uterus  a  long-continued  and 
pronounced  congestion,  such  as  the  injuries  of  childbirth,  rob- 
bing the  uterus  of  its  normal  support  and  leading  to  descent  and 
malpositions;  subinvolution;  injuries  to  the  cervix;  retroversion; 
tumors  in  the  uterus,  or  neighboring  organs;  a  sluggish  pelvic 
circulation  from  heart  or  liver  disease ;  immoderate  indulgence  in 
sexual  intercourse  and  methods  to  avoid  conception,  especially 
interrupted  coitus ;  imprudence  at  the  menstrual  period  in  catch- 
ing cold  and  overexertion  ;  the  constant  working  of  a  sewing 
machine  and  hard  work  of  any  kind  continuously  in  the  erect 
posture.  The  result  of  the  chronic  congestion  is  a  sclerosis  of 
the  myometrium,  a  great  increase  in  the  connective  tissue  between 
the  muscle-bundles,  a  thickening  of  the  arterial  coats,  and  an 
enlargement  of  the  lymph-spaces.  The  uterus  is  large,  heavy, 
and  unnaturally  firm.  In  the  ultimate  stage  the  uterine  body 
becomes  harder  than  cartilage  ;  a  heavy  scissors,  forced  together 
with  both  hands,  cuts  through  it  with  difficulty.  If  the  chronic 
metritis  is  associated  w'ith  or  caused  by  subinvolution,  there  is  a 
hyperplasia  of  muscular  as  well  as  of  connective  tissue. 

The  symptoms  of  metritis  are  a  feeling  of  weight,  drag,  and 
bearing  down  in  the  pelvis,  backache,  irritable  bladder,  constipa- 
tion, inability  to  be  long  on  the  feet,  and  a  varied  train  of  reflex 
nervous  symptoms  which  may  be  produced  by  any  of  the  pelvic 
diseases.  There  is  almost  always  menorrhagia  and  usually  a 
leukorrhea  due  to  the  endometritis  that  invariably  accompanies 
metritis.      There  is  often  an  aggravation  of  the  symptoms  with  a 


312     Displacements  and  Diseases  of  the  Uterus 

blood-tinged  mucous  discharge  midway  between  the   menstrual 
periods  (intermenstrual  pain,  "Mittelschmerz"). 

On  a  combined  examination  the  increase  in  the  size,  weight, 
and  firmness  of  the  uterus  is  easily  appreciated. 

The  trcatiiioit  must,  if  possible,  be  directed  to  the  cause  of 
the  chronic  congestion  which  is  responsible  for  the  metritis. 
There  is  therefore  the  utmost  variety  in  the  therapeutic  measures 
required  in  individual  cases.  The  injuries  of  labor  in  the  lower 
birth-canal  must  be  repaii'ed ;  a  malposition  of  the  uterus  should 
be  corrected ;  the  cervix  may  require  trachelorrhaphy  or  ampu- 
tation; tumors  in  the  pelvis  or  abdomen  may  indicate  an  opera- 
tion for  their  removal;  a  curettage  is  usually  indicated  for  the 
chronic  endometritis  that  accompanies  the  metritis;  the  sexual 
hygiene  may  demand  correction ;  digitalis  or  strophanthus  may 
prove  the  best  remedies  for  metritis  if  there  is  valvular  disease  or 
weakness  of  the  heart;  a  pill  of  stypticin  (gr.  j),  hydrastinin  (gr. 
ss),  and  ergotin  (gr.  j)  t.  i.  d.  is  an  excellent  treatment  for 
uncomplicated  subinvolution;  the  patient's  habits  of  life  or  work 
may  need  modification.  The  congestion  of  the  uterus  may  be 
temporarily  diminished  by  glycerin  tampons,  hot-water  vaginal 
douches,  multiple  punctures  of  the  cervix  (local  bloodletting), 
rest  in  bed,  and  the  assumption  of  the  knee-chest  posture  twice 
a  day  for  five  minutes  at  a  time. 

It  is  claimicd  that  chlorid  of  gold  and  minute  doses  of  bichlo- 
rid  of  mercury  bring  about  in  time  a  resolution  and  absorption 
of  the  connective-tissue  infiltration.  If  the  disease  has  reached 
its  ultimate  stage  of  conversion  of  the  uterine  body  into  a  mass 
of  the  firmest  conceivable  connective  tissue,  the  disease  is  incur- 
able. The  author  has  been  obliged  to  resort  to  hysterectomy  in 
such  cases  for  the  uncontrollable  metrorrhagia  that  was  its  most 
striking  symptom  and  that  had  resisted  repeated  curetments, 
amputation  of  the  cervix,  and  all  the  other  conservative  meas- 
ures which  are  usually  employed. 

Subinvolution. — An  arrested  or  retarded  involution  of  the 
uterus  after  childbirth  or  miscarriage  may  leave  a  large  and 
heavy  uterus  after  the  completion  of  the  puerperium,  with  a 
hyperplasia  of  both  connective  and  muscular  tissue.  The  uterus 
is  not  only  increased  in  weight  and  size,  but  is  soft  and  flabby. 
It  is  therefore  particularly  disposed  to  displacements  downward 
and  backward.  The  symptoms  of  subinvolution  are  a  sense  of 
weight  and  bearing  down,  metrorrhagia,  leukorrhea,  inability  to 
make  much  effort  in  the  erect  posture  or  to  be  long  on  the  feet, 
and  irritable  bladder.  On  examination  the  increase  in  size  and 
decrease  in  the  tonicity  of  the  womb  are  easily  appreciated.  There 
are  two  causes  of  subinvolution  that  should  always  be  looked  for: 


Siiperinvolution  and  Atrophy  313 

something-  attracting  too  much  blood  to  the  organ  or  some  mechan- 
ical obstacle  to  firm  uterine  contraction.  Under  the  first  head 
examples  are  found  in  too  early  getting  up  after  childbirth,  pre- 
mature resumption  of  sexual  intercourse,  inflammatory  action  in 
or  around  the  uterus,  obstructed  pelvic  circulation  from  heart  or 
liver  disease,  or  from  abdominal  growths,  and  tumors  of  the  uterus, 
as  fibroids.  Under  the  second  head  are  found  such  conditions  as 
adhesions  of  the  perimetrium  to  the  parietal  peritoneum  or  intes- 
tines and  the  retention  i)i  utero  of  portions  of  the  ovum,  over- 
grown decidua,  and  polypoid  tumors. 

The  treatment  should  always  be  directed  to  the  cause,  if  pos- 
sible. On  its  removal  the  involution  usually  proceeds  normally 
to  its  completion.  The  reduction  of  the  uterus  may  be  hastened 
by  a  pill  of  ergotin,  stypticin,  and  hydrastinin,  united  with  digi- 
talis or  strophanthus  if  the  circulation  is  weak  or  obstructed,  rest 
in  bed,  vaginal  douches  of  hot  water,  and  glycerin  tampons. 

Superinvolution  and  Atrophy. — If  the  process  of  puerperal 
involution  proceeds  too  far  and  lasts  too  long,  the  uterus  may  be 
practically  absorbed,  except  for  a  shrunken  mass  of  connective 
tissue  preserving  its  form  in  miniature.  In  extreme  cases  the  uterus 
is  reduced  to  the  size  of  a  peanut  or  the  end  joint  of  one's  finger. 
The  vaginal  portion  of  the  cervix  disappears  and  the  shrunken 
vaginal  vault  ends  in  the  minute  orifice  of  the  external  os.  It  is 
frequently  possible  to  observe  attenuation  of  the  uterine  walls  by 
superinvolution  without  decrease  in  the  length  of  the  uterus. 
This  condition,  to  some  extent,  is  the  rule  in  lactation  (lactation 
atrophy).  If  a  curettage  is  undertaken  in  a  uterus  of  this  kind, 
the  danger  of  perforating  the  uterine  wall  must  always  be  taken 
into  account.  Superinvolution  often  disappears  after  lactation, 
unless  it  has  reached  an  extreme  degree,  when  it  is  permanent. 
The  symptoms  are  amenorrhea  and  sterility.  On  a  bimanual 
examination  the  reduced  size  of  the  uterus  is  detected,  and  the 
attenuation  of  its  walls  is  appreciable.  The  treatment  should  be 
general.  Good  hygiene,  exercise,  full  diet,  tonics  containing 
iron,  and  a  change  of  climate,  best  from  the  interior  to  the  sea- 
shore, may  give  relief.  The  faradic  current  and  the  negative 
pole  of  a  galvanic  current  to  the  uterine  muscle  have  been  bene- 
ficial. Local  treatment  with  the  object  of  producing  a  pelvic 
congestion  and  stimulation  is  not  as  a  rule  to  be  recommended. 

Atrophy  of  the  uterus  occurs  physiologically  after  the  meno- 
pause. It  may  also  follow  operations  upon  the  cervix,  salpingo- 
oophorectomy,  inflammatory  diseases  of  the  appendages,  pressure 
upon  the  uterus  from  a  pelvic  or  abdominal  tumor,  adynamic  or 
wasting  diseases,  exophthalmic  goiter,  and  severe  mental  strain, 
hysteria,  neurasthenia,  and  insanity.      The  symptoms  are  infre- 


314     Displacements  and   Diseases  of  the  Uterus 

quent  and  scanty  menstruation  or  amenorrhea  and  steriHty. 
No  treatment  restores  an  atrophic  uterus  to  a  normal  size  and 
normal  functions  if  the  atrophy  has  advanced  to  a  considerable 
degree.  Occasionally  the  timely  removal  of  the  cause  may  be 
followed  by  an  improvement  in  the  local  condition. 

Injuries  of  the  Uterus. — Aside  from  ruptures  in  childbirth 
and  pregnancy,  the  uterus  may  be  injured  by  instruments  in 
an  operation,  as  dilatation  or  curettage,  in  attempts  to  induce 
abortion,  by  falls  upon  some  sharp  object  which  enters  the 
vagina,  and  by  a  brutal  perversion  of  the  sexual  instinct.  A 
branched  dilator  has  perforated  the  posterior  uterine  wall  not  in- 
frequently in  an  attempt  to  insert  the  instrument  in  an  anteflexed 
uterus.  The  author  has  seen  in  consultation  a  fatal  injury  of 
this  kind  from  the  Emmet  curetment  forceps.  Perforation  of  the 
uterine  wall  by  a  curet  is  a  comparatively  common  accident.  It 
has  happened  in  the  hands  of  every  experienced  operator  several 
times,  in  spite  of  particular  care  to  avoid  it ;  but  in  an  aseptic 
operation,  if  one  avoids  irrigation  of  the  uterine  cavity  after  the 
curet  is  felt  to  slip  through  the  uterine  wall  and  disappear  up  to 
the  handle,  there  are  absolutely  no  ill  results.  It  is  not  neces- 
sary to  open  the  abdomen  on  account  of  the  uterine  injury,  but 
if  the  curetment  precedes  an  abdominal  section,  the  opportunity 
may  be  taken  to  close  the  small  puncture  wound  through  the 
peritoneum  by  a  few  interrupted  catgut  sutures. 

Fatal  results  have  followed  an  intra -uterine  injection  after 
perforation  of  the  uterine  wall  by  a  curet.  ^ 

If  symptoms  of  infection  and  pelvic  peritonitis  follow  a  per- 
foration of  the  uterus,  a  free  opening  of  Douglas's  pouch  by 
posterior  colpotomy,  irrigation  of  the  pelvis,  and  drainage  afford 
the  best  chances  of  a  cure.  In  case  the  uterus  is  necrotic  from 
infection,  it  should  be  removed,  if  the  patient's  condition  warrants 
the  attempt,  by  vaginal  or  combined  hysterectomy.  The  most 
dangerous  injuries  to  the  uterus  are  the  result  of  unskilful 
attempts  to  induce  abortion,  usually  by  a  criminal  abortionist  or 
by  the  patient  herself.  Perforations  large  enough  to  allow  pro- 
lapse of  the  intestines  into  the  uterine  cavity  have  been  made  in 
this  way.  A  sound  has  been  passed  through  the  uterus,  tra- 
versing the  abdominal  cavity  and  wounding  the  liver.  The 
author  has  successfully  operated  upon  a  patient  who  pushed 
a  buttonhook  through  the  fundus  uteri  to  induce  abortion  and 
in  attempting  to  withdraw  it  caught  and  tore  a  hole  in  a  loop 

1  In  one  of  the  large  hospitals  of  Philadelphia  recently  a  resident  physician 
curetted  a  woman  for  an  incomplete  miscarriage,  perforated  the  uterine  wall  with  the 
curet,  and  then  gave  an  intra-uterine  douche  of  sublimate  solution.  More  than  a 
pint  of  this  solution  was  found  in  the  pelvic  cavity  at  the  postmortem  examination 
the  following  day. 


Hysteraloia  315 

of  intestine.  Such  injuries  are  usuall}-  fatal,  but  an  abdominal 
section,  with  repair  of  the  injury  as  far  as  possible,  removal  of 
hopelessly  infected  structures,  and  drainage  by  the  vagina,  the 
abdomen,  or  both,  ma\'  save  the  patient. 

A  case  is  recorded  in  Germany  of  a  drunken  laborer  who, 
after  copulating  with  a  woman,  tore  out  her  uterus  with  his 
hand. 

Foreign  bodies  in  the  uterus  are  rare.  Pieces  of  glass  tub- 
ing have  been  broken  off  and  pledgets  of  cotton  have  been  left 
behind  after  an  intra-uterine  application.  The  author  has  seen 
the  following  cases  :  In  one  of  the  large  German  clinics  a  leech 
applied  to  the  cervix  entered  the  uterine  cavit\',  whence  it  was 
dislodged  with  difficulty.  In  two  cases  a  tupelo  tent,  inserted  to 
induce  abortion,  had  slipped  into  the  uterine  cavity,  was  lying 
obliquely,  and  forcible  attempts  to  extract  it  with  a  forceps  had 
buried  the  lower  end  in  cervical  tissue,  where  it  was  firmly  fixed. 
A  knitting-needle  inserted  by  the  woman  herself  to  induce  abor- 
tion had  not  entered  the  cervical  canal,  but  had  penetrated  the 
myometrium  of  the  cervix  and  had  passed  up  in  the  uterine  wall 
almost  to  the  fundus.  Luckily  for  the  woman,  the  needle  had 
broken  ©ff  before  its  point  entered  the  abdominal  cavity.  By 
anesthetizing  the  patient,  if  necessary,  it  is  usually  easy  to  ex- 
tract these  foreign  bodies  by  appropriate  manipulations  or  with 
instruments,  possibly  after  the  dilatation  of  the  cervical  canal. 
Subsequently  an  intra-uterine  irrigation  and  packing  may  be  called 
for.  It  is  said  that  a  strong  solution  of  table  salt  injected  into 
the  uterine  cavity  will  make  a  living  leech  release  its  hold.  The 
custom  of  applying  leeches  to  the  cervix  is,  however,  scarcely 
known  in  America. 

Hysteralgia,  or  neuralgia  of  the  uterus,  may  be  the  expres- 
sion of  a  uterine  disease,  malaria,  or  rheumatism.  It  may  be 
idiopathic  in  nervous  women  or  those  much  reduced  in  health 
and  strength.  The  pains  are  usually  rhythmical,  occurring  about 
every  ten  minutes,  often  worse  at  night  and  in  the  supine  posi- 
tion. In  one  of  the  author's  patients  hysteralgia  occurred  regu- 
larly and  very  severely  in  alternate  weeks.  The  seat  of  pain  is 
in  the  uterine  region,  the  sacrum,  or  radiates  down  the  legs. 
It  is  often  very  severe,  robbing  the  patient  of  rest  at  night,  and  in 
time  wrecking  her  nervous  system.  Morphia  relieves  it  most 
effectuall}^,  but  the  habit  of  taking  this  drug  is  easily  acquired 
and  it  should  be  used  most  cautiously. 

The  cause  of  the  hysteralgia  should  be  removed  if  it  is  symp- 
tomatic. The  salicylates  are  effectual  in  the  rheumatic  variety. 
Quinin  and  arsenic  may  cure  it.  The  tonics  and  other  treatment 
suitable  to  neuralgias  elsewhere  may  succeed.      Garrigues  recom- 


3i6      Displacements  and  Diseases  of  the   Uterus 

mends   highly   the   positive   pole   of   a  galvanic   current   in  the 
vagina  and  uterus. 


NEOPLASMS   OF  THE  UTERUS. 

Fibromyoma^  of  the  uterus  is  a  new-growth  made  up  of  the 
constituents  of  the  uterine  walls, — that  is,  mainly  of  unstriped 
muscle-fibers  and  connective  tissue, — but  containing  also  blood- 
vessels, lymphatics,  and  possibly  nerves.  Occasionally  glandular 
structures  are  found  in  the  tumor.  A  fibromyoma  is  the  com- 
monest neoplasm  in  the  human  body.  It  may  be  found  in  the 
uterus  of  at  least  20  per  cent,  of  women  over  thirty-five  years  of 
age.  These  new-growths  are  classified  in  several  ways  :  If  the 
muscular  tissue  predominates,  the  tumor  is  a  myoma ;  if  the 
connective  tissue  predominates,  a  fibroma  ;  if  the  two  structures 
are  well  represented,  as  is  usual,  it  is  a  fibromyoma  ;  if  there  is 
glandular  structure  within  the  tumor,  it  is  an  adenomyoma.  A 
myoma  may  be  diffuse  if  it  is  incorporated  intimately  with  the 
structure  of  the  uterine  wall  and  is  not  inclosed  in  a  well-defined 
capsule.  A  fibroma  is  usually  encapsulated  or  discrete.  The 
most  convenient  classification,  clinically,  is  based  upon  the  rela- 
tion of  the  tumor  to  the  uterine  wall,  the  endometrium,  and  the 
perimetrium.  Thus  a  fibromyoma  may  be  interstitial,  submu- 
cous, or  subperitoneal.  The  two  latter  varieties  may  have  one  of 
two  forms,  sessile  or  pedunculate.  Another  division,  according 
to  the  situation  of  the  tumor,  is  into  corporeal  and  cervical  fibro- 
mata. As  subdivisions  of  the  latter  the  tumor  may  be  subperi- 
toneal if  it  grows  from  the  anterior  or  posterior  wall,  intralig- 
amentary  if  it  grows  laterally,  and  a  fibromyoma  of  the  vaginal 
portion  if  it  grows  downward.  It  is  a  submucous  and  probably 
a  fibro-adenomatous  tumor  if  it  grows  into  the  cervical  canal. 
Finally,  there  is  a  classification  based  upon  the  degenerative  or 
pathological  processes  observed  in  fibromyomata  ;  they  may  be 
edematous,  fatty,  amyloid,  myxomatous,  cystic,  calcified,  necro- 
biotic,  necrotic,  sarcomatous,  cancerous,  telangiectatic  (vascular 
or  lymphatic),  and  atrophic. 

Pathological  Anatomy  and  Histology. — A  fibromyoma  originally 
is  interstitial  and  in  its  earliest  stage  is  always  a  myoma,  the  pre- 
dominance of  fibrous  tissue  only  appearing  after  the  tumor  has 
reached  the  size  of  a  cherry.  The  histogenesis  and  etiology  of 
the  growth  are  as  yet  obscure.  It  has  been  claimed  that  the 
tumor  originates  in  the  muscular  walls  of  an  artery,  the  vessel 
forming  a  pedicle  around  and  upon  which  the  growth  develops. 

1  The  synonyms  of  fibromyoma  are  leiomyoma,  fibroma,  myoma,  fibroid,  recur- 
rent fibroid,  hysieroma, grossessejiireusf,  myoma  laevecellulare,  fibrous  tumor. 


Fibromyoma  of  the  Uterus 


317 


A  more  generally  accepted  view  is  that  the  tumor  develops  from 
the  muscle-fibers  of  the  myometrium.  The  cause  of  the  growth 
is  as  obscure  as  the  origin  of  other  tumors.  There  seems  to  be 
a  connection  between  sterility  and  the  formation  of  fibromyomata. 
It  is  indisputable  that  more  fibromyomata  are  found  in  unmarried 
women  of  middle  age,  in  women  who  have  borne  one  or  two 
children  years  before,  than  in  married  women  who  have  married 
early  and  have  borne  a  number  of  children.  It  has  been  asserted, 
therefore,  that  the  uterine  muscle,  denied  the  opportunity  of  a 
physiological  hypertrophy  in  repeated  pregnancies,  is  prone  to 
the  pathological    formation  of   musculofibrous  tissue  in   conse- 


Fig.  319. — Symmetrical  enlargement  of  uterus  by  a  fibromyoma. 


quence  of  such  stimuli  as  coitus,  masturbation,  or  ungratified 
sexual  desire.  This  theory,  however,  leaves  unexplained  the 
occasional  occurrence  of  fibroids  in  young  women  and  in  women 
who  conceive  early  and  frequently.  It  must  be  confessed  that 
the  etiology  of  fibromyomata  is  still  among  the  unsolved  problems 
of  medical  science.  A  fibromyoma  is  rarely  single.  As  many 
as  1 50  tumors  have  been  found  in  the  uterus.  ^  Often  one  tumor 
exceeds  the  other  so  much  in  bulk  that  the  subordinate  masses 
may  easily  be  overlooked.  The  tumor  or  tumors  are  as  a  rule 
discrete,  surrounded  by  a  capsule  out  of  which  they  can  easily 
be  enucleated.  Between  the  capsule  and  the  tumor  are  the 
blood-vessels  from  which  the  latter  is   nourished.      The  blood- 

1  Bland  Sutton,  "Brit.  Med.  Jour.,"  April  6,  1901. 


3iS      Displacements  and   Diseases  of  the  Uterus 

supply  is  scanty.  Occasionally  the  growth  is  diffuse,  unencap- 
sulated,  and  blended  with  the  myometrium.  The  latter  form  is 
more  frequently  seen  in  the  lower  portion  of  the  uterus ;  it  is  a 
myoma  rather  than  a  fibroma  and  is  vascular.  The  myometrium 
undergoes  the  same  development  in  response  to  the  stimulus  of 
a  growing  fibromyoma  that  it  does  in  pregnancy.  There  are  the 
same  rhomboidal  arrangements  of  the  hypertrophied  muscle- 
bundles  in  the  uterine  wall  that  are  seen  in  the  gravid  womb.  A 
fibromyoma  is  subjected  to  pressure  from  the  surrounding  layers 
of  uterine  muscle  which  encapsulate  it.  If  the  growth  begins 
approximately  in  the  middle  of  the  uterine  wall,  there  is  equal 
pressure  upon  the  sides  of  the  tumor  and    it  remains  intersti- 


Fig.  320. — Symmetrical  enlargement  of  uterus,  with  subperitoneal  excrescence. 

tial,  embedded  in  the  uterine  wall.  Frequently  there  is  an 
unequal  pressure  upon  the  growth  so  that  a  displacement  occurs 
in  the  direction  of  least  resistance,  inward  toward  the  uterine 
cavity  until  the  growth  is  submucous  with  a  half  or  more  of  its 
periphery  covered  by  mucosa,  outward  toward  the  abdominal 
cavity  until  the  growth  is  subperitoneal  with  the  greater  part  of 
its  periphery  covered  by  perimetrium  which  tightly  adheres  to  it, 
or  laterally  between  the  layers  of  the  broad  ligament.  The 
form  of  the  tumor  is  usually  spherical.  Different  shapes  may 
be  assumed  in  consequence  of  pressure  exerted  upon  the  tumor 
by  the  uterus  itself  or  by  surrounding  structures.  An  irregular 
lobulated  form  is  common  from  the  fact  that  two  or  three  tumors 


Fibromyoma  of  the  Uterus  319 


Fig.  321. — Fibromyoma  with  multiple  subperitoneal  bosses. 


Fig.  322. — Large  subperitoneal  fibromyoma  from  posterior  uterine  wall  (Porro-Cesa- 

rean  section). 


320     Displacements  and  Diseases  of  the  Uterus 


Fig.    323. — Large  subperitoneal  fibromyoma  springing  from  right  uterine  cornu. 


Fig.   324. — Fibromyoma  of  uterus,  with  intraligamentary  growth  on  left  side. 


Fibromyoma  of  the  Uterus 


;2i 


Fig.    325. — Submucous  fibroma  removed   by  hysterectomy  in   the   early  puerperium. 


Fig.  326. — Interstitial  fibromyoma  of  fundus  uteri  (Olshausen). 


32  2     Displacements  and  Diseases  of  the  Uterus 

may  be  grouped  together,  each  in  its  own  capsule,  but  forming  a 
common  mass.      Submucous  tumors  may  conform  to  the  shape 


Fig.   327. — Fibromyoma  of  anterior  uterine  wall. 

of  the  distended  uterine  cavity.  The  pressure  to  which  they  are 
subjected  and  the  accessibihty  of  the  lower  pole  to  microbic  in- 
fection often  determine  a  necrosis  of  the  most  dependent  portion. 


Fig.    328. — Uterine  cavity  deflected  at  right  angles  in  interstitial  fibromyoma  of  the 

fundus  uteri. 


The  subperitoneal  tumors  frequently  have  a  slender  pedicle  and 
are  usually  spherical   in  shape  or  else  have  the  form  of  a  potato 


Fibromyoma  of  the   Uterus  323 

with  rounded  projecting  bosses.      In  the  former  case  the  tumor 
is   often   a   soft   myoma  ;    in   the    latter,  a   hard    fibroma.      By  a 


Fig.  329. — Uterine  cavity  in  fibromyoma  of  posterior  uterine  wall. 

torsion  of  the  pedicle  the  tumor  may  be  severed  from  its  connec- 
tion with  the  uterus  and  remain   free  in  the  abdominal   cavity  or 


Fig.  330. — Uterine  cavity  in  fibromyoma  of  anterior  uterine  wall. 

become  attached  to  other  structures.     The  uterus  itself  as  a  ped- 


324     Displacements  and   Diseases  of  the  Uterus 

icle  of  the  tumor  has  been  subjected  to  a  twist  of  120  degrees  or 
more,  and  in  one  case  (Lennander)  the  corpus  was  thus  separated 
from  the  cervix.  In  interstitial  and  submucous  tumors  the 
uterine  cavity  is  usually  much  lengthened  and  may  be  peculiarly 
distorted  in  shape  and  direction.  It  may  be  entirely  obliterated. 
In  a  case  of  Landau's  serial  transverse  sections  of  the  whole 
uterus  failed  to  show  a  uterine  cavity  under  the  microscope.  In 
a  case  of  the  author's  (Fig.  331)  the  uterine  cavity  could  not  be 
found  macroscopically  in  serial  sections. 

In  a  large  proportion  of  cases  (54  per  cent,  Tait)  the  uterine 
appendages  are  diseased.  There  is  salpingitis  and  ovaritis ;  the 
tubes  are  occluded  and  distended,  often  with  pus.      The   ureters 


Fig.   331. — Obliteration  of  the  uterine  cavity  in  a  fibromyoma  of  the  uterus. 


and  the  bladder  are  often  displaced  and  compressed.  One  ureter 
may  run  over  the  top  of  an  intraligamentary  myoma  and  may  be 
much  thickened  and  enlarged.  There  may  be  a  corresponding 
hydronephrosis.  The  bladder  may  be  lifted  surprisingly  high 
into  the  abdominal  cavity  by  a  cervical  myoma,  reaching  to  the 
umbilicus  in  a  condition  of  moderate  distention.  There  may  be 
such  pressure  upon  the  bladder  and  urethra  that  marked  vesical 
irritability  or  even  complete  retention  of  urine  results. 

There  is  a  curious  relation  between  fibromyomata  of  consid- 
erable size  and  long  growth  and  degenerative  changes  in  the 
heart — fatty  degeneration  and  brown  atrophy  of  the  cardiac 
muscle.  Sudden  deaths  from  this  cause  are  not  uncommon, 
especially   after   operation.      Hofmeier   collected    18    cases,    and 


Fibromyoma  of  the  Uterus 


325 


Fig.    332. — Gross  appearance  of  an  interstitial  fibromyoma  on  section. 


Fig.  333. — Small  interstitial  myoma  developed  around  an  artery  (Gebliard). 


3 


26     Displacements  and   Diseases  of  the  Uterus 


there  is  no  surgeon  of  experience  who  has  not  had  to  deplore 
such  a  result,  which  it  is  occasionally  impossible  to  predict  or  to 
prevent.  Under  a  low-power  magnifying  glass  the  fibers  of  a 
fibromyoma  appear  to  be  arranged  in  whorls,  aggregated  to  form 
nodes  which  are  separated  from  one  another  by  loose  connective 
tissue  in  which  are  small  blood-vessels.  Under  higher  powers 
of  the  microscope  it  is  impossible  to  demonstrate  a  regular 
order  or  arrangement  of  the  muscle-bundles  or  cells  or  of  the 
connective -tissue   fibers.      Gebhard    calls   attention    to   an   inter- 


Fig.   334. — Loofah-sponge  like  structure  of  a  myoma  (Gebhard). 

lacing  arrangement  which  he  has  observed  like  the  structure  of  a 
loofah-sponge. 

The  individual  muscle-cells  measure  in  length  0.045-0.480 
millimeter;  they  are  spindle-shaped,  with  pointed  and  sometimes 
branched  ends;  the  nuclei  are  rod- or  spindle-shaped  and  stain 
well ;  the  cell  boundaries  are  indistinct.  The  connective-tissue 
fibers  separating  the  muscle-bundles  are  composed  of  very  long 
spindle-shaped  cells,  with  nuclei  and  nucleoli.  "Mastzellen" 
abound  in  many  specimens.  They  are  supposed  to  be  metamor- 
phosed connective  tissue  and  muscle-cells.  The  arteries  entering 
the  nodes  of  a  fibromyoma  are  said  to  lose  or  be  without  the 
adventitia,  the  cells  of  the  muscular  coat  being  in  direct  relation 
with   the    elements   of   the   myoma;    hence  the  theory   that  the 


Fibromyoma  of  the  Uterus 


327 


m\^oma  begins  its  development  from  the  muscular  coat  of  tlie 
arteries  in  the  uterine  wall  and  not  from  the  myometrium  proper. 
Hertz  claims  to  have  demonstrated  the  innervation  of  myomata,^ 
but  his  observations  are  not  confirmed.  The  most  interest- 
ing and  important  result  of  the  histological  study  of  myomata 
has  been  the  discovery  of  glandular  structures  in  a  small 
proportion.  Schroeder  and  others  pointed  out  this  fact  more 
than  twenty  years  ago,  attributing  to  the  glands  an  origin  from 
the  endometrium.  Richer  found  five  examples  in  thirty-five 
specimens   of    myomata  examined,    always  in  those   under  the 


Fig.  335. — Adenomyoma  of  uterus:  ^.s,  Gland-spaces  lined  with  columnar 
epithelium ;  7n,  myometrium,  circularly  arranged  around  collection  of  glands ;  v, 
blood-vessels  (McConnell  and  J.  C.  Hirst). 

perimetrium,  farthest  away  from  the  endometrium.  In  1896  v. 
Recklinghausen  2  claimed  that  these  glandular  structures  were 
derivatives  either  of  the  uterine  mucosa  or  of  the  Wolffian 
bodies.  In  the  former  case  the  tumor  is  in  the  center  of  the 
anterior,  posterior,  or  lateral  uterine  wall,  or  surrounds  the 
uterine  cavity  like  a  ring ;  the  continuity  of  the  glands  in  the 
tumor  with  those  of  the  mucosa  is  demonstrable.  In  the  latter 
case  the  tumor  is  always  in  the  posterior  uterine  wall  or  in  the 
cornua.      The  main  bulk  of  the  tumor  is  interstitial,  bulging  into 


1896. 


"Virchow's  Archiv,"  Bd.  xlvi,  p.  235. 

"Die  Adenomyome  u.   Cystadenome  der  Uterus  u.  Tubenwandung, "  Berlin, 


o 


28      Displacements  and   Diseases  of  the  Uterus 


the  abdominal  cavity  under  the  perimetrium ;  it  is  never  encap- 
sulated. It  may  present  one  of  four  forms :  a  hard  tumor  with 
muscular  structure  predominating;  a  cystic  tumor,  with  numer- 
ous cavities  plainly  visible ;  a  soft  tumor  with  a  predominance 
of  glandular  structures;  a  telangiectatic  or  angiomatous  tumor 
with  greatly  dilated  blood-vessels.  The  gland-spaces  in  these 
tumors  have  a  peculiar  arrangement :  there  is  a  main  canal  into 
which  branch  canals  open  one  after  another.  The  picture  sug- 
gests a  comb,  the  branch  canals  presenting  the  teeth,  the  main 
canal  the  back.  From  Cullen's  investigations  it  would  appear 
that  the  majority  at  least  of  adenomyomata  are  derived  from  the 
epithelial  structures  of  Miiller's  ducts.  The  epithelium  of  adeno- 
myomata may  undergo  cancerous  degeneration,  as  one  of  Cullen's 
specimens  demonstrates ;  whether  there  is  a  special  tendency  to 
such  degeneration  in  these  tumors  is  not  yet  clear. 

The  Degenerative  or  Pathological  Changes  in  Fibromyomata. — 
/.  Edema. — Thrombosis  of  the  vessels  in  a  fibromyoma  is  fol- 
lowed by  edema.  There  may  be  no  obstruction  of  the  vessels, 
but  sufficient  pressure  on  the  large  pelvic  trunks  to  cause  an 
intense  passive  congestion.  It  is  difficult  to  differentiate  col- 
loid and  myxomatous  degeneration  from  edema.  Specimens 
of  the  former  have  been  described  as  edematous  tumors. 
Meslay  and  Hyenne  ^  describe  three  stages  of  edema  :  Simple 
imbibition  of  serum  in  a  part  of  the  tumor  ;  separation  of  the 
muscle-bundles,  formation  of  small  spaces  filled  with  a  gelatinous 
fluid,  the  cavity  walls  not  lined  by  endothelium,  but  by  the 
fibromuscular  bundles  ;  coalescence  of  these  spaces  to  form 
larger  cysts.  It  is  likely  that  the  last  two  stages  really  represent 
myxomatous  degenerations,  though  the  authors  quoted  claim 
that  the  gelatinous  fluid  was  chemically  akin  to  blood-serum  and 
contained  no  mucin,  creatin,  or  creatinin.  The  remarkable  vari- 
ability in  the  bulk  of  a  fibromyoma  so  frequently  noted  is  doubt- 
less due  to  a  temporary  edema  and  to  the  subsequent  absorption 
of  the  serum.  It  is  a  common  observation  that  fibroids  increase 
markedly  in  size  prior  to  menstruation  and  decrease  afterward. 

2.  Fatty  dege>ieratio7i  is  common  in  interstitial  and  submucous 
tumors.  It  is  most  frequently  seen  in  the  puerperium  and  may 
be  the  means  of  spontaneous  cure  by  an  involution  of  the  tumor. 
The  fat  globules  are  found  in  the  muscle-cells  and  in  the 
"  Mastzellen,"  giving  to  the  tumor  a  characteristic  appearance,  a 
yellow  mottled  surface  on  section.  A  considerable  portion  of  the 
fibromyoma  may  be  converted  into  a  lipoma. 

J.   Amyloid  degeneration  is   reported  by  Stratz.  ^      The  tumor 

'  "Ann.  de  Gyn.,"  1898,   These  de   Paris,    1898. 
^  "  Zeitschr.  f.    Geburtsh.    u.  Gyn.,"  1889,  Bd.  xvii. 


Fibromyoma  of  the  Uterus 


329 


was  a  small  submucous  fibromyoma  attached  to  the  fundus. 
The  connective  tissue  had  undergone  a  degeneration  which  gave 
the  amyloid  reaction  with  iodin  and  methyl  blue. 

^.  Mvxomatoiis  degeneration  is  frequently  seen  in  small  por- 
tions of  interstitial,  submucous,  and  intraligamentary  growths. 
The  intercellular  substance  exhibits  the  degenerative  process. 
The  tumor  on  section  looks  like  a  mass  of  yellowish-green  semi- 
solid jelly  with  trabecular  of  firmer  tissue  running  through  it  and 
masses  of  undegenerated  fibromyomatous  tissue  here  and  there. 
Considerable  areas  may  have  liquefied  into  cyst-spaces  containing 
a  serous  fluid.      Microscopically  cell-nuclei  are  found  widely  sep- 


Fig.    336. — Complete  myxomatous  degeneration  of  a  large  submucous  myoma. 


arated,  and  isolated  masses  of  cells  in  scattered  groups  are  seen. 
The  main  bulk  of  the  section  is  made  up  of  coagulated  homo- 
geneous intercellular  substance  with  an  indistinct  network  of 
fibers.  The  arterial  walls  are  usually  affected  by  the  degenera- 
tion, though  unaltered  blood-vessels  may  run  through  the 
tumor.  Myxomatous  degeneration  is  said  to  be  most  frequent 
in  pregnancy.  It  is  usually  accompanied  by  a  sudden  and  great 
enlargement  of  the  tumor. 

5.  Cystic  degeneration  of  a  fibromyoma  is  explained  by  a 
myxomatous  degeneration,  by  edema,  by  the  distention  of  gland- 
spaces  in  an  adenomyoma,  and  by  telangiectases  of  the  blood-  or 
lymph-vessels.       The    gland-spaces    are    recognized    under    the 


oo^ 


Displacements  and   Diseases  of  the  Uterus 


microscope  by  their  epithelial  lining-.  The  dilated  blood-vessels 
and  blood-spaces  contain  large  quantities  of  blood.  The  lymph- 
angiectasis  is  recognized  by  the  endothelial  lining  of  the  cyst 
cavities  and  the  yellow  coagulable  fluid  that  they  contain. 

6.  Calcification  of  a  fibromyoma  is  an  atrophic  change.  All 
further  growth  ceases  and  the  tumor  remains  stationary  in  size. 
It  is  stony  hard,  in  color  like  yellow  ivory.  The  lime  salts  are 
mainly  carbonates  and  phosphates.  The  mass  has  a  laminated 
structure  and  is  brittle.  By  treatment  with  hydrochloric  acid  the 
fibrous  and  muscular  tissue  of  which  the  tumor  was  originally 


Fig.  337. — Telangiectatic  interstitial  myoma  (Rnge). 


composed  may  be  demonstrated.  Calcification  may  occur  in 
submucous,  interstitial,  or  subperitoneal  growths.  It  has  been 
asserted  that  bony  and  cartilaginous  metamorphoses  could  be 
demonstrated  in  fibromyomata.  There  is  always  a  suspicion  that 
such  growths  were  really  calcified  fibroids  or  "uterine  stones." 
It  is  claimed,  however,  that  Freund  and  Ascher  have  observed 
respectively  an  osteomyoma  and  a  myochondroma.  ^ 

7.  Necrobiosis  occurs  if  the  nutrition  of  a  fibromyoma  is 
suddenly  cut  off,  and  if  there  is  no  infection  of  the  dead  tissue. 
The  tissue  softens,  becomes  reddish  in  color,  undergoes  fatty  de- 

'   Veit's  "  Handbuch,"  vol.  ii,  p.  442. 


Fibromyoma  of  the  Uterus 


331 


generation,  and  liquefies.  A  toxemia  may  result  if  a  large  mass  is 
affected  by  necrobiosis  on  account  of  the  absorption  of  degenerated 
material  into  the  lymphatics  even  though  infection  does  not  occur. 
Necrobiosis  is  usually  seen  in  interstitial  tumors.  The  contiguity 
of  the  intestines  in  subperitoneal  growths  and  the  exposure  of 
submucous  tumors  to  infection  usually  determines  a  necrosis  if 
the  blood-supply  of  such  tumors  is  cut  off  The  necrobiosis  be- 
gins in  the  center  of  the  interstitial  tumor  which  is  furthest  from 
the  blood-vessels  that  enter  it  from  the  periphery. 

8.  Necrosis  occurs  if  a  fibromyoma  is  infected.  The  lower 
pole  of  a  submucous  fibroma  springing  from  the  fundus  is  very 
commonly  the  seat  of  inflammation  and  gangrene,  as  its  nutrition 


Fig.   338. — Necrosis  of  an  intraligamentary  fibromyoma. 


is  poor  and  its  infection  is  likely.  Any  submucous  tumor  is  liable 
to  necrosis.  It  is  rare  in  interstitial  growths  and  not  at  all 
common  in  subperitoneal  tumors,  though  the  contiguity  of  the 
intestines  and  their  contained  micro-organisms  always  makes  an 
infection  possible,  especially  if  adhesions  form  between  the  pe- 
riphery of  the  myoma  and  the  intestinal  walls.  The  source  of 
infection  may  also  be  a  pyosalpinx.  All  of  the  fibromyomata 
are  peculiarly  liable  to  infection  and  necrosis  after  childbirth. 
The  pressure  to  which  they  are  subjected,  the  sudden  disturbance 
of  their  blood-supply,  and  the  susceptibility  of  a  puerpera  to  in- 
fection of  the  blood-current  and  of  the  lymphatics  make  necro- 


oo- 


Displacements  and   Diseases  of  the  Uterus 


sis  of  a  fibroid  in  the  puerperium  probable.  The  author  has 
operated  on  four  such  cases.  Necrosis  has  followed  the  electrical 
treatment  of  fibroids,  the  administration  of  ergot,  curettage,  and 
even  the  introduction  of  a  uterine  sound.  A  process  allied  to 
necrosis,  but  clinically  different,  is  suppuration  of  the  capsule 
without  involvement  of  the  tumor  itself.  By  this  process  the 
tumor  may  exhibit  a  spontaneous  enucleation  and  be  expelled 
from  the  woman's  body.  Such  an  occurrence  is  more  likely  in 
submucous  tumors,  but  Olshausen  has  seen  two  fibroids  thus 
discharged  through  an  abscess  in  the  abdominal  walls. 

Necrosis  of  a  fibromyoma,  except  in  the  puerperium  and  in 
polypoid  submucous  tumors,  is  rare.  Olshausen  states  that  in 
many  hundred  fibroids  under  his  observation  he  has  never  seen 
it.  The  author  has  had  six  cases,  four  in  the  puerperium,  one 
in  a  submucous  tumor  that  had  caused  complete  inversion  of  the 
uterus,  and  one  following  electropuncture  of  the  growth. 

g.  Malignant  Dege)ieratio)is. — Sarcomatous  degeneration  of  a 
fibromyoma  is  not  uncommon.  It  is  accompanied  by  a  sudden 
enlargement  of  the  tumor,  the  disappearance  of  the  fibrous  tissue, 
and  often  a  necrobiosis  of  the  soft  intracapsular  mass.  There  is 
a  rapid  extension  of  the  disease  to  surrounding  tissues  and  struc- 
tures. The  unstriped  muscle-cells  are  converted  into  spindle 
sarcoma  cells.  A  peculiar  variety  of  sarcoma  is  the  rhabdomyoma 
or  tumor  of  striped  muscle-iiber  observed  in  cervical  polyps. 
Carcinomatous  degeneration  is  explained  either  by  extension  of 
an  adenocarcinoma  from  the  endometrium  into  the  tumor  or  by 
carcinoma  of  the  epithelium  in  an  adenomyoma. 

lo.  Atrophy  of  a  fibromyoma  may  occur  after  the  menopause, 
in  the  involution  of  the  puerperium,  after  castration,  and  in  con- 
sequence of  a  diminished  blood-supply  by  ligation  of  the  arteries, 
or  by  some  such  means  as  partial  torsion  of  the  pedicle,  pressure 
upon  the  vessels,  or  thrombosis.  It  is  usually  a  slow  process. 
The  muscle-fibers  shrink  and  undergo  fatty  degeneration  ;  the 
fibrous  tissue  contracts  like  scar  tissue,  and  in  time  a  tumor  of 
considerable  size  may  completely  disappear. 

The  Influence  of  Fibromyomata  upon  the  Uterine  Appendages  and 
upon  the  Endometrium.  — In  almost  all  submucous  and  interstitial 
tumors  there  is  a  hyperplastic  endometritis,  the  glandular  or  the 
interstitial  structures  predominating  in  individual  specimens  or 
being  equally  hypertrophied.  In  rare  instances  the  pressure  of 
a  large  tumor  upon  the  endometrium  results  in  its  atrophy.  In 
subperitoneal  tumors  the  endometrium  may  be  unaffected.  The 
tubes  and  ovaries  are  diseased  in  a  large  proportion  of  fibroids. 
There  may  be  interstitial  salpingitis  and  endosalpingitis  with 
hemato-,  hydro-,  or  pyo-salpinx.      The  ovaries  are  enlarged  by 


Fibromyoma  of  the  Uterus 


333 


an  increase  and  enlargement  of  the  follicles  and  an  overgrowth 
of  connective  tissue.  There  is  an  increase  in  the  number  of 
corpora  fibrosa,  a  hyaline  degeneration  of  the  vessels,  and  a  pre- 
mature disappearance  of  the  primordial  follicles  (Gebhard). 

Clinical  History,  Symptoms,  and  Diagnosis. — A  fibroid  tumor  is 
usually  first  discovered  in  a  woman  after  her  thirty-fifth  year  ; 
cases  are  recorded  in  young  girls  eighteen  years  of  age  and  up- 
ward, but  they  are  comparatively  rare  in  women  under  thirty. 
The  rate  of  growth  is  very  slow,  especially  if  the  tumor  is  com- 
posed mainly  of  fibrous  tissue.  Five,  ten,  and  fifteen  years  may 
be  required  for  the  tumor  to  reach  the  size  of  an  adult  head, 
hence  very  large  fibroid  tumors  are  rare,  for  the  menopause  is 
reached  and  passed  before  the}^  can  attain  great  bulk.  Cases  are 
recorded,  however,  of  tumors  weighing  135  and  140  pounds.     If 


Fig.    339.- — Large  fibromyoma,  weighing  onl}'  23  pounds. 


the  growth  is  a  myoma,  the  weight  is  surprisingly  light  compared 
with  the  bulk,  as  muscular  tissue  is  not  heavy.  Figure  339 
represents  a  case  in  which  all  the  available  room  in  the  abdom- 
inal cavity  was  occupied  by  a  myoma  that  weighed  only  twenty- 
three  pounds.  Ordinarily  the  growth  of  the  tumor  ceases  at 
the  menopause,  but  exceptional  cases  are  recorded  of  a  rapid 
growth  after  the  cessation  of  menstruation.  In  such  cases  ad- 
hesions to  the  omentum  furnish  the  main  blood-supply  to  the 
tumor.  Growth  often  ceases  long  before  the  menopause,  perhaps 
in  consequence  of  degenerative  changes  in  the  tumor,  or  without 
alteration  in  its  structure.  Every  experienced  specialist  has  ob- 
served cessation  of  growth  and  an  unaltered  size  in  the  tumor 
over  periods  of  ten  years  or  more.  The  first  symptom  to  attract 
attention  is  usually  menorrhagia,  in  the  shape  of  increased  and 
prolonged    menstruation,    which    produces    in    time    a    marked 


334     Displacements  and   Diseases  of  the  Uterus 

anemia.  1  In  the  intervals  between  the  flow  the  patient  regains 
some  of  her  lost  blood,  but  is  again  reduced  by  another  hemor- 
rhage. The  intervals  between  the  periods  are  often  gradually- 
lessened  until  there  is  a  continuous  dribbling  of  blood,  with  ex- 
acerbations of  hemorrhage  at  periods  corresponding  to  the  men- 
struation or  at  odd  times.  There  may  be,  however,  complete 
absence  of  discharge  during  the  whole  history  of  the  case  between 
the  monthly  periods.  Exceptionally  the  menstrual  flow  may  be 
unaltered,  diminished,  or  altogether  absent.  The  last  condition  is 
usually  seen  in  subperitoneal  or  intraligamentary  growths  or  in 
the  rare  cases  of  atrophy  of  the  endometrium  from  pressure. 

Leukorrhea  often  appears  in  the  intermenstrual  periods  on 
account  of  the  hypertrophic  glandular  endometritis.  In  rare 
cases  the  discharge  becomes  excessive.  In  one  instance  a 
leukorrhea  that  soaked  the  woman's  night-dress  to  the  shoulders 
every  night  was  really  a  lymphorrhea,  enlarged  lymphatic  ducts 
being  discovered  after  removal  of  the  tumor,  opening  into  the 
uterine  cavity. 

Pain  is  not  often  noted.  There  is  usually  not  even  discom- 
fort from  a  tumor  of  considerable  size,  which  is  often  discovered 
accidentally  in  a  pelvic  or  abdominal  examination,  the  woman 
herself  being  unconscious  of  its  presence.  In  subperitoneal 
pedunculated  tumors  pain  may  be  caused  by  the  "insults"  to 
which  neighboring  abdominal  structures  are  subjected  by  the 
movements  of  the  tumor,  and  ascites  may  result,  but  the  latter 
is  a  rare  accompaniment  of  fibromyomata.  If  the  growth  is  in- 
carcerated in  the  pelvis  or  is  very  large,  distressing  symptoms 
may  appear  in  consequence  of  pressure  on  the  sacrosciatic  nerves, 
on  the  pelvic  blood-vessels,  the  bladder,  and  rectum.  Neuralgic 
pains  may  dart  down  the  legs,  or  there  may  be  a  loss  of  power ; 
edema  and  varices  of  the  lower  limbs  and  of  the  abdomen  may 
be  noted  ;  there  may  be  obstinate  constipation  to  complete  ob- 
struction of  the  bowels;  the  bladder  maybe  irritable  or  there 
may  be  retention  of  urine.  Pressure  on  the  ureters  may  obstruct 
the  flow  of  urine  and  may  ultimately  produce  hydronephrosis. 
The  diminution  of  resisting  power  in  the  urinary  tract  caused  by 
pressure  may  determine  its  infection. 

The  degenerations  of  a  fibroid  tumor  may  be  productive  of 
special  symptoms.  Cystic  degeneration  is  accompanied  by  rapid 
growth,  with  the  .symptoms  that  always  accompany  sudden  dis- 
tention of  the  abdomen — pain,  orthopnea,  and  cardiac  embarras- 
ment.  Sarcomatous  degeneration  also  occasions  a  marked  in- 
crease in  the  size  of  the  tumor,  but  even  before  the  increased  size 

^  The  menorrhagia  is  due  to  the  hyperplastic  endometritis  and  to  the  increased 
area  of  the  endometrium. 


Fibromyoma  of  the  Uterus 


335 


is  observed  there  may  be  a  noticeable  reduction  in  health  and 
strength,  an  ill-defined  feeling  of  discomfort  or  pain,  and  ca- 
chexia. Necrosis  is  accompanied  by  the  general  symptoms  of 
sepsis  and  often  of  localized  inflammation.      If  the  tumor  is  sub- 


Fig.  340. — Fibroid  tumor. 

mucous  and  necrotic,  there  is  likely  to  be  a  foul  discharge  sug- 
gesting cervical  or  corporeal  cancer  and  often  leading  to  a  mis- 
taken diagnosis. 


Fig.   341. — Fibroid  tumor. 

Necrobiosis  of  a  large  tumor  may  occasion  an  autointoxica- 
tion evidenced  by  malaise,  headache,  loss  of  appetite  and  weight, 
and  coated  tongue.  Edema  of  a  fibroid  leads  to  variations  of  size 
in  the  tumor  as  the  serum  is  exuded  and  again  absorbed.      It  is 


336     Displacements  and   Diseases  of  the  Uterus 

a  common  experience  to  witness  a  regular  increase  in  the  size  of 
a  fibromyoma  during  the  premenstrual  congestion  ;  it  has  been 
asserted  that  by  the  amount  of  increase  in  size  at  this  time  one 
may  predict   the   seventy  of  the  menorrhagia.      The  sudden  ex- 


Fig.  342. — Fibroid  tumor. 


Fig.    343. — Intraligamentary  cyst  and  fibroid  tumor  of  the  uterus. 

pansion  of  the  tumor  may  be  accompanied  by  pain,  especially  if 
there  are  inflammation  and  adhesions  of  the  appendages. 

The  diagnosis  of  a  fibromyoma  is  usually  easy.  There  are 
the  subjective  symptoms  of  hemorrhage  and  perhaps  of  an 
abdominal  growth  presented  commonly  by  a  middle-aged  woman. 


Fibromyoma  of  the  Uterus  Tf2>7 

The  objective  symptoms  are  the  enlargement  of  the  uterus,  its 
firm  consistency  and  irregularity  of  outline,  the  bosses  or  knobs 
of  a  fibroid  on  the  peritoneal  surface  being  plainly  appreciable  as 
a  rule  in  a  combined  examination.  The  objectiv^e  symptoms, 
however,  are  not  always  plain  and  the  diagnosis  may  be  exceed- 
ingly difficult.  If  the  tumor  is  regular  in  outline  and  soft  in  con- 
sistency, it  may  suggest  strongly  a  pregnant  uterus  ;  but  there  is 
the  history  of  slow  growth  and  usually  of  menorrhagia.  The 
author  knows  of  a  case  in  which  a  positive  diagnosis  of  pregnancy 
and  a  coincident  fibroid  was  made  on  account  of  the  statement 
of  the  patient  that  there  had  been  an  amenorrhea  of  nine  months' 
duration.  A  Cesarean  section  was  attempted,  but  no  fetus  was 
found.  A  submucous  fibromyoma  symmetrically  distending  the 
uterus  may  be  difficult  to  differentiate  from  a  pregnancy 
with  detachment  of  the  placenta.  An  intra-uterine  exploration 
after  dilatation  of  the  cervical  canal  is  the  only  means  of  arriv- 
ing at  a  correct  conclusion.  A  subperitoneal  pedunculated 
fibroid  with  a  slender  pedicle,  especially  if  it  has  become 
detached  from  the  uterus,  may  be  mistaken  for  a  growth  of 
some  other  abdominal  organ.  It  is  usually  possible  to  recog- 
nize the  connection  of  the  tumor  with  the  uterus  by  having  an 
assistant  make  traction  upon  it,  if  possible,  through  the  abdominal 
wall  upward  toward  the  diaphragm,  which  makes  the  pedicle 
tense  and  so  appreciable  in  a  bimanual  examination.  The 
commonest  error  in  the  differential  diagnosis  is  to  mistake 
some  other  growth  for  a  fibroid.  An  old  pus-tube  with  thick 
walls  and  firm  adhesions  is  often  regarded  as  a  fibro- 
myoma. Any  solid  tumor  of  the  pelvis  is  almost  invariably  be- 
lieved to  be  a  fibroid  until  the  abdomen  is  opened.  Thus, 
fibromyomata  of  the  broad  ligament,  fibromata  of  the  ovary,  and 
ovarian  pregnancies  have  all  been  operated  upon  for  fibroids  of 
the  uterus.  The  commonest  and  unfortunately  the  most  serious 
mistake  is  to  regard  a  pregnant  uterus  as  a  fibroid  tumor.  A 
patient  was  sent  to  the  author  from  a  distant  State  for  hysterec- 
tomy on  account  of  what  was  supposed  to  be  a  large  fibroid. 
She  was  pregnant  with  twins.  There  was  no  fibroid.  Time  and 
again  hysterectomies  have  been  performed  by  operators  of  ex- 
perience in  cases  of  intra-uterine  pregnancy  without  a  trace  of  a 
fibromyomatous  growth  in  the  uterus.  ^  There  is  a  peculiar  con- 
dition of  the  gravid  womb  in  which  such  mistakes  are  difficult  to 
avoid.  There  is  a  history  of  profuse,  long-continued,  and  unin- 
terrupted bleeding  ;  there  has  been  no  amenorrhea  ;  the  uterus  is 
the  size  of  a  six  months'  pregnancy ;  it   is   impossible,  without 

1  Five  such  operations  of  which  the  author  has  personal  knowledge  have  been 
performed  in  the  hospitals  of  Philadelphia  within  a  few  years. 

22 


2,^8     Displacements  and  Diseases  of  the  Uterus 

exploration  of  the  entire  uterine  cavity,  to  demonstrate  the  pres- 
ence of  an  ovum  in  it,  but  in  the  upper  portion  of  the  cavity  is  a 
three  or  four  months'  ovum,  retained  for  some  time,  causing  hem- 
orrhage from  the  time  of  impregnation  and  a  continued  bleeding 
after  the  death  of  the  embryo.  The  uterus  is  distended  far  more 
by  accumulated  blood-clots  than  by  the  size  of  the  ovum. 

A  careful,  methodical  exploration  of  the  uterine  cavity  should 
enable  one  to  avoid  such  a  mistake.  In  pregnancy  there  is  always 
much  more  room  in  the  cavity  by  the  eccentric  hypertrophy  of 
the  uterine  walls  than  is  ever  found  in  a  case  of  fibromyoma.  The 
ovum  should  be  discovered  although  deep  exploration  may  be 
necessary  to  detect  it.  A  submucous  growth  has  a  consistency 
very  different  from  that  of  the  ovum,  and  in  almost  all  submucous 
as  well  as  in  interstitial  tumors  the  intra-uterine  cavity  is  irregular 
in  shape  and  direction. 

The  Treatment  of  Fibromyomata  of  the  Uterus. — Many  cases 
require  no  treatment  at  all.  If  the  woman  has  no  discomfort;  if 
the  menorrhagia  is  moderate,  does  not  exist,  or  the  patient  is  past 
the  menopause  ;  if  there  is  no  further  growth  in  the  tumor  and 
no  evidence  of  pathological  change  in  it,  such  as  necrosis,  cystic 
or  sarcomatous  degeneration,  even  palliative  treatment  is  uncalled 
for  and  radical  treatment  is  unjustifiable.  The  woman  should  be 
instructed  to  report  to  her  physician  every  six  months  for  an  exam- 
ination, and  a  series  of  notes  should  be  kept  showing  the  size 
of  the  tumor  and  the  development  of  new  symptoms,  local  or 
general.  Every  specialist  of  experience  has  under  his  observation 
for  years  cases  which  show  no  increase  in  the  size  of  the  tumor  and 
no  symptoms  whatever  except  perhaps  a  moderate  menorrhagia.  In 
a  certain  proportion  of  these  cases,  especially  after  the  menopause, 
there  is  a  decrease  in  the  size  of  the  tumor,  occasionally  an  almost 
complete  disappearance.  But  patient  and  physician  must  often  be 
reconciled  to  a  postponement  of  the  menopause  beyond  the  usual 
period  by  ten  or  fifteen  years.  If  in  the  course  of  repeated  exam- 
inations, or  when  the  patient  first  seeks  advice,  the  uterine  hem- 
orrhages are  a  distinct  disadvantage  to  her,  palliative  treatment  at 
least  is  indicated. 

Palliatn'C  Treatment. — The  main  object  of  this  treatment  is 
to  diminish  the  hemorrhage.  Incidentally  the  bulk  of  the  tumor 
may  be  reduced,  but  such  a  result  is  not  to  be  expected.  Oc- 
casionally the  incarceration  of  the  tumor  in  the  pelvis  demands 
its  elevation.  The  uterine  hemorrhages  may  be  lessened  or 
entirely  stopped  by  the  exhibition  of  drugs,  hygienic  manage- 
ment, the  application  of  electricity,  curettage,  intra-uterine  appli- 
cations, the  removal  of  the  ovaries  and  tubes,  and  the  ligation  of 
the  arteries  supplying  the  uterus. 


The  Treatment  of  Fibromyomata  of  Uterus      339 

Medicinal  Trcatinciit. — For  a  long  time  ergot  by  the  mouth 
or  ergotin  hypodermatically  was  the  routine  treatment  of  the 
hemorrhages  from  a  fibroid  tumor.  Little  is  heard  of  it  now. 
The  results  achieved  do  not  warrant  the  internal  administration  of 
ergot  for  months  and  years  or  the  hypodermatic  injections  of 
ergotin  twice  a  week  for  months  at  a  time,  that  Hildebrandt  ad- 
vocated (1872)  and  that  some  years  ago  were  universally  prac- 
tised all  over  the  civilized  world.  The  disadvantages  of  the 
treatment  outweighed  its  occasional  advantages.  There  is,  how- 
ever, one  result  to  be  hoped  for  in  individual  instances.  A  tumor 
becoming  submucous  by  the  contraction  of  the  uterine  muscle 
may  be  pushed  out  farther  in  less  time  into  the  uterine  cavity  by 
the  prolonged  use  of  ergot  than  it  would  have  been  without  this 
stimulus  to  powerful  uterine  contractions  and  may  so  become 
more  easily  amenable  to  enucleation  by  way  of  the  cervical  canal. 
The  author  has  had  the  best  results  in  the  medicinal  treatment  of 
the  metrorrhagia  of  fibroids  by  a  combination  of  ergotin  (gr.  j), 
st\'pticin  (gi'-j),  and  hydrastinin  (gr.  ss)  in  pill  four  times  a 
day,  beginning,  if  possible,  a  week  before  the  expected  flow  and 
continued  while  it  lasts.  When  these  remedies  have  failed,  supra- 
renal extract  has  occasionally  been  successful.  This  animal 
extract  gives  better  results  than  mammary  or  thyroid  extract. 
But  all  medicinal  treatment  of  the  hemorrhages  is  uncertain 
and  in  a  considerable  proportion  of  cases  quite  futile. 

Hygienic  Treatment. — Everything  that  causes  pelvic  con- 
gestion should  be  avoided ;  constipation,  coitus,  working  a 
sewing  machine,  prolonged  effort  on  the  feet,  tight  clothing, 
corsets,  are,  as  far  as  possible,  to  be  interdicted.  At  the  men- 
strual period  the  patient  should  stay  in  bed,  at  least  for  the  first 
few  days.  The  habit  should  be  cultivated  of  lying  down  regu- 
larly once  or  twice  a  day  for  an  hour  or  two,  and  the  regular 
assumption  of  the  knee-chest  posture  night  and  morning  for  five 
minutes  at  a  time  should  be  recommended.  The  baths  in  Ger- 
many and  England  (Kreuznach,  Schwalbach,  Woodhall)  that 
have  been  regarded  as  most  beneficial  for  fibroid  tumors  do  not 
aid  the  patient  in  the  least,  as  far  as  the  author's  observation 
goes,  except  that  change  of  air  and  scene  and  a  well-regulated 
life  may  always  be  productive  of  improvement  in  the  general 
health.  The  diet  should  be  ordered  with  the  idea  of  resupply- 
ing  the  blood  lost  at  the  periods.  A  full  diet  with  plenty  of  soup 
and  milk  is  indicated.  Malt,  iron,  digitalis,  and  strychnia  are 
usually  called  for  between  the  periods. 

The  Electrical  Treatment. — The  enthusiasm  at  first  aroused 
by  Apostoli's  method  has  completely  died  out.  The  unpreju- 
diced gynecologist  has  lost  faith  in  it  either  by  personal  experi- 


340     Displacements  and  Diseases  of  the  Uterus 

mentation  or  by  observation,^  and  has  learned,  moreover,  that 
it  is  by  no  means  free  from  risk.  Electropu nature  of  fibro- 
myomata,  the  application  of  strong  galvanic  currents  to  reduce 
the  bulk  of  the  tumor,  must  be  unreservedly  condemned.  One 
good,  however,  has  come  from  a  world-wide  trial  of  the  electrical 
treatment  of  fibroids.  We  have  at  our  command  in  selected  and 
suitable  cases  a  valuable  hemostatic  agent  in  the  positive  pole  of 
a  galvanic  current  inserted  in  the  uterine  cavity.  There  should  be 
a  rheostat  and  a  galvanometer  to  govern  and  to  indicate  the  force 
of  the  current,  which  is  most  conveniently  derived  from  the  street 
current  for  lighting  purposes.  The  positive  wire  is  attached  to  a 
uterine  sound,  the  end  of  which  is  of  platinum,  the  handle 
being  insulated.  A  movable  insulating  sheath  is  also  provided 
on  the  sound.  The  negative  wire  is  attached  to  a  large  pad,  wet 
with  salt  water,  to  be  placed  upon  the  abdomen.  The  vagina  is 
carefully  cleansed.  The  instruments  required  are  boiled.  A 
bivalve  speculum  is  inserted  and  the  cervix  is  cleansed  with 
pledgets  of  cotton  soaked  in  a  i  :  lOOO  bichlorid  solution;  it  is 
then  seized  with  bullet  forceps  and  pulled  down;  the  uterine 
sound  is  inserted  as  far  as  it  will  go  without  force  and  the 
insulating  sheath  is  pushed  up  to  the  cervix,  to  guard  the 
vagina;  the  speculum  is  removed  and  the  current  is  gradually 
turned  on  until  the  galvanometer  registers  20  to  30  milliamperes 
at  the  first  treatment.  In  subsequent  applications  much  stronger 
currents  maybe  used;  Apostoli  says  to  250  milliamperes,  but 
many  do  not  employ  more  than  from  55  to  60  milliamperes. 
Forty  milHamperes  is  usually  enough.  The  current  should  be 
maintained  at  its  highest  point  for  from  four  to  ten  minutes,  and 
then  should  be  gradually  turned  off.  The  vagina  is  douched 
again  and  the  patient  rests  absolutely  a  while  after  the  treatment, 
remaining  at  home,  after  leaving  the  physician's  office,  till  the 
following  day.  Two  or  three  treatments  a  week  are  given ;  thirty 
treatments  in  all  are  usually  required.  The  galvanic  current 
applied  in  this  way  acts  as  a  cauterant,  destroying  the  super- 
ficies of  the  hypertrophied  endometrium  and  forming  an  eschar. 
It  is  contraindicated  by  any  degenerative  process  in  the  tumor 
and  by  inflammatory  disease  of  the  appendages. 

Curettage. — If  the  uterine  cavity  is  simply  elongated  and  not 
distorted,  if  the  tumor  is  not  submucous,  but  interstitial,  curettage 
may  be  of  distinct  service.  Schroeder  once  observed  necrosis 
of  a  submucous  tumor,  the  capsule  of  which  had  probably  been 
perforated  by  the  curet  with  a  consequent  infection  of  the  tumor. 

^The  author  was  one  of  a  committee  of  three  appointed  by  the  Philadelphia 
County  Medical  Society  to  investigate  this  treatment.  In  three  years'  time  not  a 
single  case  was  presented  to  us  of  a  tumor  reduced  in  size  by  electrical  treatment. 


The  Treatment  of  Fibromyomata  of  Uterus      341 

Olshausen  in  an  enormous  experience  has  never  seen  an  alarm- 
ing symptom  after  the  use  of  the  curet,  and  it  is  probable  that 
an  aseptic  operation  is  always  perfectly  safe  in  a  suitable  case. 
This  has  been  the  author's  experience.  In  many  cases  the  tortu- 
ous course  and  the  inequalities  of  the  uterine  cavity  make  a  curet- 
tage impossible,  and  it  should  never  be  undertaken  without  con- 
sidering the  possible  risk  of  infecting  a  submucous  tumor. 

Iiitra-utcrine  Applications. — As  a  result  of  personal  experi- 
ence Veit  1  strongly  recommends  intra-uterine  apphcations  in 
tumors  of  moderate  size  in  women  near  the  menopause  who 
suffer  only  from  metrorrhagia,  stating  that  he  has  often  con- 
trolled the  hemorrhage  in  this  way  for  months  at  a  time.  He 
uses  laniinaria  tents  soaked  for  some  time  in  a  95  per  cent,  solu- 
tion of  carbolic  acid  in  alcohol  to  dilate  the  cervix  ;  the  uterine 
cavity  is  explored  with  the  finger;  if  the  tumor  is  submucous,  it 
is  enucleated;  if  not,  a  considerable  quantity  of  iodin  or  solution 
of  chlorid  of  iron  is  injected  with  a  Braun's  intra-uterine  syringe. 
The  former  is  not  so  efficient,  but  does  not  cause  uterine  colic  ;■ 
the  latter  does,  often  violently.  The  author  has  no  experience 
with  this  treatment  and  would  hesitate  to  use  it,  preferring  as  a 
palliative  measure  the  galvanic  current  or  the  curet. 

Salpiiigo-oopJiorcctoiny. — Since  Trenholme  and  Hegar  per- 
formed the  first  operations  of  castration,  in  1876,  to  check  the 
hemorrhage  from  fibroid  tumors,  the  number  recorded  has  been 
sufficiently  large  to  permit  the  formulation  of  definite  rules  and 
statements  as  to  indications,  limitations,  and  results.  Castration 
may  be  expected  to  accomplish  satisfactory  results  in  checking 
hemorrhage  and  effecting  a  reduction  in  the  size  of  the  tumor  in 
75  to  90  per  cent,  of  suitable  cases.  It  is  not  to  be  depended 
upon  except  in  interstitial  tumors  of  moderate  size.  It  is  contra- 
indicated  by  cystic  degeneration.  The  operation  is  by  no  means 
as  easy  or  as  safe  as  castration  under  ordinary  circumstances. 
The  uterus  is  ordinarily  turned  on  its  long  axis  so  that  the  right 
ovary  is  posterior  to  the  tumor  and  inaccessible.  The  ovaries 
are  not  infrequently  embedded  in  adhesions  or  are  spread  out  on 
the  surface  of  the  tumor.  The  large  blood-vessels  in  the  broad 
ligaments  are  easily  injured  and  fatal  hemorrhage  has  occurred 
from  puncture  wounds  of  the  pedicle  needle.  Infection,  also,  is 
more  likely  than  in  other  operations  upon  the  broad  ligaments. 
Every  scrap  of  ovarian  tissue  must  be  removed  if  the  operation 
is  to  be  a  success,  which  is  occasionally  impracticable. '  In  10  to 
I  5  per  cent,  of  cases  continued  hemorrhage  or  steady  growth  of 
the  tumor  necessitates  later  a  myomectomy,  an  enucleation  of  a 
submucous  tumor,  or  a  hysterectomy.      In  view  of  these  disad- 

1  "  Handbuch  der  Gynakologie." 


342      Displacements  and  Diseases  of  the  Uterus 

vantages  and  of  the  limitation  of  the  operation  to  moderate-sized 
interstitial  growths,  it  is  not  regarded  with  favor  by  the  majority 
of  operators.  It  has,  however,  its  place,  and  should  not  be  for- 
gotten in  a  case,  say,  of  weak  heart,  in  which  on  opening  the  ab- 
domen conditions  are  found  favorable  for  it. 

Ligation  of  Arteries  Siipplying  the  Utertis. — Ligation  of  the 
ovarian  artery  to  diminish  the  blood-supply  to  a  fibroid  tumor 
was  proposed  and  carried  out  by  von  Antal  and  by  Schroeder 
more  than  twenty  years  ago.  Rydyzier  ^  in  1889  ligated  the 
six  arteries  supplying  the  uterus,  with  temporary  success,  but 
bleeding  returned  later  to  such  a  degree  that  the  patient  died  of 
anemia.  Lately  the  operation  has  been  revived  with  consider- 
able enthusiasm.  The  usual  method  and  the  one  to  be  recom- 
mended is  the  opening  of  the  anterior  vaginal  vault  and  the  sepa- 
ration of  the  bladder  from  the  uterus ;  the  opening,  also,  of  the 
posterior  vaginal  vault,  and  the  ligation  of  the  vessels  in  the 
broad  ligament,  the  uterine  artery  being  isolated  and  tied  on 
both  sides.  If  easily  practicable  by  the  vaginal  route,  it  is  much 
easier  to  tie,  next  the  artery  of  the  round  ligament,  and  finally 
the  ovarian  artery,  the  pedicle  needle  having  a  short,  sharp  curve 
and  being  inserted  from  and  emerging  again  upon  the  anterior 
surface  of  the  broad  ligament,  the  forefinger  of  the  left  hand 
inserted  through  the  opening  in  Douglas's  pouch  guarding  and 
directing  the  needle-point.  An  abdominal  section  may  be  neces- 
sary to  tie  the  upper  arteries  of  the  broad  ligament.  The  opera- 
tion is  only  suitable  for  tumors  of  moderate  size,  interstitial  in 
situation,  that  have  undergone  no  degenerative  process.  The 
field  for  it  is  very  limited.  The  author's  experience  with  it  has 
been  disappointing. 

The  Radical  Treatment  of  Fibromyomata. — Removal  of  Myoma- 
tons  Polyps. — If  the  tumor  is  moderate  in  size  with  a  slender 
pedicle  it  may  be  seized  with  a  volsella  forceps  and  twisted  off  by 
rotary  movement  of  the  instrument  on  its  long  axis.  If  the  ped- 
icle is  too  thick  to  be  treated  in  this  manner,  the  safest  plan  is  to 
make  Avith  scissors  or  a  knife  a  circular  incision  around  its  base 
and  to  enucleate  the  pedicle.  If  the  latter  is  inaccessible,  it  may 
be  necessary  to  slip  the  noose  of  a  wire  ecraseur  around  it  and  to 
cut  it  off  by  tightening  the  wire.  There  is,  however,  always  dan- 
ger in  this  method  of  partially  inverting  the  uterine  wall  and  of 
removing  a  portion  of  it,  possibly  making  an  orifice  into  the  peri- 
toneal cavity.  The  cervical  canal  ordinarily  gapes  widely  enough 
to  permit  easy  access  to  a  myomatous  polyp.  If  it  does  not, 
one  of  the  methods  of  artificially  dilating   it  may  be   required : 

'  "  Wien.  klin.  Wochenschr.,"  1890,  No.  10  ;   "  Centralbl.  f.  Gyn.,"  1893,  No. 


The  Radical  Treatment  of  Fibromyomata       343 

namely,  branched  dilators,  bougies,  incisions,  or  laminaria  tents 
soaked  for  some  time  in  a  95  per  cent,  solution  of  carbolic  acid 
in  alcohol. 

Tlie  Enucleation  of  Sjibnmcous  Tumors. — A  submucous  tumor 
of  considerable  size  may  be  removed  by  the  vagina.  Veit 
claims  that  any  tumor  which  can  be  pressed  into  the  pelvic 
canal  from  above  may  be  removed  in  this  manner.  The  usual 
limitation  of  size  is  that  of  the  fetal  head.  A  preparatory  wide 
dilatation  of  the  cervical  canal  is  necessar)-.  Laminaria  tents 
prepared  in  the  manner  already  described  are  a  convenient  means 
of  obtaining  the  dilatation.  They  are  inserted  the  night  before 
the  operation. 

It  is  always  necessary  to  be  prepared  to  widen  the  cervical 
canal  by  separating  the  cervix  from  the  anterior  vaginal  vault, 
dissecting  off  the  bladder  and  making  an  incision  through  the 
whole  length  of  the  cervix  in  the  median  line  anteriorly.  The 
tumor  being  rendered  easily  accessible  in  this  manner,  the  finger- 
tip is  pushed  through  the  friable  mucous  capsule  at  the  most 
prominent  accessible  portion  and  the  capsule  is  stripped  off  suf- 
ficiently far  to  grasp  the  tumor  itself  with  tenaculum  forceps. 
Traction  on  the  tumor  and  a  further  stripping  back  of  the  capsule 
make  it  possible  to  free  the  tumor  and  to  deliver  it,  often  with 
surprising  ease. 

Abdo7ninal  Hysterectomy. — Successive  improvements  in  the 
technic  of  this  operation,  due  to  Schroeder,  Chrobak,  Baer,  and 
others,  have  made  it  the  most  satisfactory  of  all  the  operations 
for  fibroid  tumors.  It  is  adapted  to  tumors  of  any  shape,  size, 
or  position,  but  it  involves  a  mutilation  of  the  patient  which 
should  be  avoided  if  it  is  easily  possible  to  remove  the  tumor  alone 
and  to  leave  the  uterus  in  good  condition.  Hence  it  is  usually 
restricted  to  large  interstitial  growths,  to  submucous  tumors 
too  large  to  remove  by  the  pelvic  route,  to  subperitoneal  tumors 
with  too  large  a  pedicle  to  ligate  safely,  or  with  too  deep  a  bed 
after  enucleation  to  be  managed  successfully,  to  intraligamentary 
growths  that  can  not  readily  be  removed  separately,  and  to 
tumors  that  have  undergone  degeneration. 

The  technic  of  the  operation  may  be  thus  described  :  An 
abdominal  incision  is  made  long  enough  to  permit  the  delivery  of 
the  tumor  from  the  abdominal  cavity.  Adhesions,  if  they  exist, 
are  carefully  severed,  perfect  hemostasis  being  secured.  The 
tumor  is  seized  by  the  fingers  hooked  under  its  upper  margin  and 
is  delivered  through  the  abdominal  wound.  The  patient  is  raised 
in  the  Trendelenburg  position.  The  intestines  are  covered  with  a 
large  pad.  An  assistant  retracts  one  side  of  the  abdominal  wall 
with  a  retractor.     A  ligature  of  silk  or  catgut  on  a  pedicle  needle 


344     Displacements  and  Diseases  of  the  Uterus 

secures  the  ovarian  artery  on  this  side  ;  another,  tied  over  the 
first,  the  artery  of  the  round  Hgament.  A  hemostat  is  fas- 
tened to  the  outer  edge  of  the  broad  Hgament  over  these 
Hgatures.  A  clamp  is  fastened  to  the  whole  width  of  the  broad 
ligament  above  the  hemostat,  far  enough  away  to  enable  the 
operator  to  cut  conveniently  between  the  two  instruments.  Before 
closing  the  clamp  its  points  are  pressed  firmly  against  the  tumor 
so  that  they  shall  secure  all  the  blood-vessels.  The  broad  liga- 
ment is  then  cut  between  the  hemostat  and  the  clamp  to  the 
periphery  of  the    tumor    or   to   the  wall    of  the    uterus.      The 


Fig.  344- 


-Ligation   of  the  ovarian  artery  and   the  artery  of  the  round  ligament; 
division  of  the  broad  Hgament  between  clamps. 


ascending  branch  of  the  uterine  artery  is  cut  at  this  point.  Before 
it  is  cut  or  directly  afterward  it  is  seized  with  a  hemostat.  The 
same  procedure  is  carried  out  on  the  opposite  side.  A  knife  is 
then  drawn  across  the  anterior  face  of  the  uterus  at  a  height 
which  insures  the  bladder  against  injury,  joining  the  incisions  in 
the  broad  ligaments  and  going  deep  enough  to  cut  through  the 
capsule  of  the  tumor  if  it  is  situated  in  this  region  or  to  furnish 
a  flap  of  peritoneum  with  some  underlying  muscular  tissue.  A 
similar  incision  is  made  posteriorly,  the  uterus,  held  at  the  fundus 
by  heavy  volsella  forceps,  being  pulled  backward  for  the  anterior 
and  forward  for  the  posterior  incision.     The  uterus  is  now  held 


The  Radical  Treatment  of  Fibromyomata      345 

only  by  the  cervix.  Before  amputating  it  at  the  level  of  the  internal 
OS,  the  uterine  arteries  are  tied  by  plunging  sharp-pointed  pedicle 
needles  with  different  angles  through  the  bases  and  between  the 
layers  of  the  broad  ligaments,  under  the  arteries,  and  near  enough 
to  the  cervix  to  insure  the  ureters  from  inclusion  in  the  ligatures. 
On  the  side  nearest  the  operator  the  thumb  and  forefinger  should 
catch  the  artery  about  half  an  inch  from  the  cervix  and  the 
pedicle  needle  should  be  inserted  between  the  fingers  and  the 
cervix,  the  point  of  the  needle  being  inclined  away  from  the 
operator.  The  same  is  done  on  the  other  side,  except  that  the 
point  of  the  needle  is  inclined  toward  the  operator.  The  cervix 
is  now  cut  across  with  heavy  scissors  and  the  uterus  is  removed. 
The  cervical  walls  are  joined  with  a  few  interrupted  sutures  if 
there   is   much  oozins:.      A  continuous  suture  beginning   on  the 


Fig.    345. — Closure  of  peritoneum  over  tlie  stump  after  hysterectomy  by  supravaginal 
amputation  of  tlie  uterus. 

operator's  side  tucks  in  the  stumps  of  the  ovarian  arteries  and 
the  round  ligaments,  closes  the  upper  edges  of  the  broad  liga- 
ments and  the  peritoneal  flaps  over  the  cervix.  The  abdominal 
cavity  is  carefully  cleansed  and  dried  and  the  abdomen  is  closed. 
Two  modifications  of  this  technic  are  occasionally  indicated  : 
one,  the  removal  of  the  entire  uterus  with  the  cervix — panhys- 
terectomy; the  other,  the  ligation  of  one  broad  ligament,  its 
transverse  section,  the  ligation  of  the  uterine  artery,  the  ligation 
of  the  ovarian  artery  and  that  of  the  round  ligament  on  the  other 
side ;  then  the  section  of  the  cervix,  the  division  of  the  uterine 
artery  on  the  opposite  side,  its  ligation,  and  the  separation  of  the 
broad  ligament  from  below  upward. 

Panhysterectomy  is  indicated  if  there  is  malignant  disease  of 


346     Displacements  and  Diseases  of  the  Uterus 

the  uterus,  infection  of  the  tumor  or  of  the  uterus,  or  if  it  is 
desired  to  drain  the  pelvis  by  way  of  the  vagina.  In  general, 
supravaginal  amputation  of  the  uterus  is  to  be  preferred  as  a 
quicker,  easier  operation,  with  less  risk  of  injury  to  the  ureters, 
and  leaving  a  more  natural  condition  of  the  vaginal  vault. 

The  technic  of  panhysterectomy  differs  from  that  of  supra- 
vaginal amputation  only  in  the  complete  separation  of  the  cervix 
from  the  vaginal  vault.  This  is  most  conveniently  effected 
if  the  woman  has  borne  children  and  the  vagina  is  capacious, 
by  beginning  the  operation  by  the  vagina  ;  making  a  circular 
incision  around  the  vaginal  portion  of  the  cervix,  opening 
the  anterior  and  posterior  cul-de-sac,  and  detaching  the  cer- 
vix laterally  as  far  as  the  cervicovaginal  branch  of  the  uterine 
artery.  The  vagina  is  then  packed  with  gauze,  the  rubber 
gloves  are  changed,  the  abdomen  is  opened,  and  the  broad  liga- 
ments are  severed  as  already  described.  After  the  ligation 
of  the  uterine  arteries  it  is  only  necessary  to  join  the  in- 
cisions opening  the  anterior  and  posterior  peritoneal  reduplica- 
tions with  the  incisions  in  the  broad  ligaments  and  to  cut  the  par- 
ametrium on  either  side  of  the  cervix  to  the  median  or  inner  side 
of  the  ligated  blood-vessels.  The  uterus  is  then  lifted  out  en- 
tire. The  vaginal  walls  may  be  joined  by  two  or  three  interrupted 
catgut  sutures  running  anteroposteriorly  or  may  be  .".eft  open  for 
drainage.  The  edges  of  the  broad  ligaments  and  the  flaps  of 
peritoneum  attached  in  front  to  the  bladder  and  behind  to  the 
rectum  are  joined  by  a  running  stitch  of  catgut.  After  the  ab- 
domen is  closed  the  packing  is  removed  from  the  vagina,  as  it  is 
soaked  with  blood,  and  is  replaced  by  fresh  sterile  gauze.  If  the 
operation  is  not  begun  by  the  vagina,  the  vaginal  vault  may  be 
opened  from  above,  laterally,  posteriorly,  or  anteriorly,  as  the 
operator  prefers,  the  usual  custom  being  to  introduce  an  instru- 
ment into  the  vagina,  such  as  a  closed  Emmet  curetment  forceps, 
and  to  cut  down  upon  it  as  a  guide  while  an  assistant  presses  it 
firmly  upward.  The  author's  habit,  however,  has  been  to  dissect 
the  cervix  from  the  bladder  from  above  until  the  dissection 
reaches  a  point  below  the  tip  of  the  vaginal  portion  which  is 
plainly  felt  through  the  vaginal  wall ;  then,  by  cutting  directly 
backward  through  the  anterior  vaginal  wall  in  the  median  line, 
the  vagina  is  opened.  It  is  then  easy  to  cut  the  vaginal  vault 
and  the  parametrium  around  the  cervix  after  the  ligation  of  the 
six  arteries  of  the  broad  ligaments. 

The  separation  of  the  uterus  by  severing  first  the  broad  liga- 
ment from  above  downward,  then  amputating  the  cervix  or 
detaching  it  from  the  vaginal  vault  and  severing  the  opposite 
uterine  artery  and  broad  ligament  from  below  upward,  is  indicated 


The  Radical  Treatment  of  Fibromyomata       347 

in  intraligamentary  fibroids.  The  broad  Hgament  on  the  un- 
affected side  is  Hgated  and  separated  in  the  usual  manner  ;  the 
ovarian  artery  and  that  of  the  round  Hgament  are  ligated  on  the  op- 
posite side  ;  the  cervix  is  cut  across,  the  uterine  artery  is  clamped 
and  cut,  and  the  intraligamentary  growth  is  rolled  out  of  its  bed  in 
the  broad  ligament  from  below  upward.  The  ureter  occasionally 
runs  over  such  a  tumor  ;  by  this  manoeuver  it  slips  outward  away 
from  the  tumor,  drops  into  the  bed  left  by  the  tumor,  and  thus 
escapes  injury.  The  large  raw  space  left  between  the  layers  of 
the  broad   lis:ament  should  be  drained.      If  the   cervical    canal 


Owes. 


oundiiy- 


Fig.  346. — Left  ovarian  vessels  tied,  vesical  peritoneum  divided  and  pushed 
down,  and  left  uterine  vessels  ligated.  Cervix  amputated  and  uterus  pulled  up  and 
out,  exposing  right  uterine  artery,  which  is  clamped  an  inch  above  the  cervical  stump. 
The  two  following  steps  are  clamping  the  right  round  ligament  and  right  ovarian 
vessels,  when  the  mass  is  removed  (Kelly). 


gapes,  a  supravaginal  amputation  permits  of  sufficient  drainage 
by  a  strip  of  gauze  pushed  through  it  into  the  vagina,  the  peri- 
toneum being  closed  over  the  cervix,  as  usual,  by  a  continuous 
suture  ;  if  sufficient  drainage  can  not  be  secured  by  way  of  the 
cervical  canal,  a  panhysterectomy  is  indicated,  the  vaginal  vault 
being  left  open  and  packed  with  gauze,  but  the  peritoneal  flaps 
being  united  above  to  close  the  abdominal  cavity. 

The  Enucleation  of  a  Fibromyonia  by  Abdominal  Section."^ — ^In 
^  Olshausen  gives  Spiegelberg  the  credit  of  priority  in  the  operation  (1874). 


348     Displacements  and  Diseases  of  the  Uterus 

a  study  of  specimens  removed  by  hysterectomy  it  not  infrequently 
has  appeared  that  the  tumor  might  have  been  removed  from  its 
bed,  leaving  the  sexual  organs  in  a  normal  condition  for  subse- 
quent child-bearing.  In  every  celiotomy  the  tumor  and  its  rela- 
tionship with  the  uterus  should  be  carefully  studied  to  determine 
whether  a  mutilation  of  the  patient  may  be  avoided.  In  many 
interstitial  growths,  as  well  as  in  subperitoneal  tumors,  it  is 
possible  to  remove  the  tumor  alone.  This  is  naturally  most 
desirable  in  young  women  of  child-bearing  age,  not  only  to 
avoid  an  enforced  sterility,  but  also  the  ill  effects  of  a  premature 
menopause.  But  the  unfavorable  features  of  a  myomectomy 
must  also  receive  consideration.  If  the  tumors  are  multiple,  the 
removal  of  each  one  from  its  bed  may  be  a  tedious  procedure, 
dangerously  prolonging  the  operation  ;  it  is  always  possible  to 
overlook  a  small  growth  which  may  subsequently  grow  and  de- 
mand another  operation  ;  the  uterine  wall  may  be  so  mutilated  that 
it  can  not  endure  the  distention  of  a  subsequent  pregnancy  and 
may  rupture  ;  if  the  bed  of  the  tumor  is  large,  or  if  many  must 
be  closed,  the  obliteration  of  the  dead  spaces  may  be  difficult  or 
impossible,  oozing  of  blood,  if  not  hemorrhage,  is  to  be  feared, 
and  infection  is  likely  to  occur.  It  is  not  possible  to  lay  down 
dogmatic  rules  as  to  the  choice  between  myomectomy  and 
hysterectomy. 

A  careful  but  rapid  inspection  and  palpation  of  the  uterus 
and  tumor,  the  patient's  age  and  circumstances,  a  consideration 
of  the  advantages  and  disadvantages  of  the  two  operations  must 
determine  the  question  in  the  individual  case.  It  is  a  safe  rule, 
when  in  doubt,  to  select  hysterectomy  as  the  surer  and  safer 
operation. 

If  myomectomy  by  enucleation  is  determined  upon,  an  in- 
cision is  made  over  the  most  prominent  portion  of  the  tumor, 
through  its  capsule.  When  the  white  glistening  surface  of  the 
tumor  is  exposed,  it  is  shelled  out  of  its  bed  by  the  fingers, 
blood-vessels  around  its  periphery,  if  necessary,  being  clamped 
and  afterward  tied.  The  bed  from  which  the  tumor  is  removed 
is  immediately  reduced  in  size  by  the  contraction  of  the  myo- 
metrium which  surrounds  it,  but  even  so  it  is  not  always  easy  to 
obliterate  the  cavity.  It  is  usually  necessary  to  trim  off  redun- 
dant portions  of  the  capsule.  The  best  way  to  obliterate  the 
bed  of  the  tumor  is  to  introduce  series  of  interrupted  catgut 
sutures  in  tiers,  beginning  in  the  bottom  of  the  cavity  and  ending 
by  sutures  of  the  perimetrium.  In  cavities  of  moderate  size  a 
continuous  tier  suture  or  a  mattress  suture  is  the  most  convenient 
and  quickest  method.  Oozing  may  necessitate  the  use  of  mattress 
sutures.      It  has  been  found  advisable  in  individual  instances  to 


The  Radical  Treatment  of  Fibromyomata       349 

perforate  the  inner  capsule  of  the  tumor  and  to  drain  its  bed  by  a 
gauze  strip  passed  into  the  uterine  cavity  and  out  of  the  cervix, 
the  abdominal  cavity  being  shut  off  by  suturing  the  outer  capsule 
of  the  tumor. 

Tlic  amputation  of  subperitoneal  pedunculated  tunwrs  may 
be  an  exceedingly  easy  and  simple  operation  if  the  pedicle  is 
small.  The  author  has  removed  a  tumor  weighing  more  than 
ten  pounds  attached  to  the  fundus  uteri,  by  transfixing  and  ligat- 
ing  a  pedicle  scarcely  larger  than  his  thumb.  If  the  pedicle  is 
large  and  fleshy,  its  secure  ligation  may  be  difficult  or  impossible 
and  a  hysterectomy  ma\'  be  preferable  to  the  myomectomy.  In- 
terlacing or  chain  ligatures  may  answer  the  purpose,  or  the  elastic 
ligature,  recommended  and  used  by  Olshausen,  Sanger,  Treub,  and 
many  other  German  and  French  operators,  may  be  the  easiest  and 
quickest  way  of  securing  the  stump.  The  elastic  ligature  is  a  solid 
rubber  cord  soaked  for  many  hours  or  da}'s  before  use  in  a  strong 
sublimate  solution,  stretched  tightly  around  the  pedicle,  secured 
where  its  ends  cross  by  a  silk  ligature,  the  ends  cut  off  short,  and 
the  rubber  cord  around  the  stump  left  in  the  abdominal  cavity, 
which  is  closed  without  drainage. 

The  most  satisfactory  way  of  dealing  with  the  pedicle,  if  it  is 
practicable,  is  to  enucleate  or  to  excise  it  by  a  wedge-shaped  ex- 
cision, the  blood-vessels  being  secured  separately,  if  possible, 
or  closed  by  deep  sutures  under  the  wedge-shaped  wound. 
Deep  interlacing,  interrupted  sutures  in  the  myometrium  com- 
pletely surrounding  the  pedicle  and  tightly  tied,  or  mattress 
sutures  traversing  the  bed  of  the  pedicle,  may  secure  a  more 
perfect  hemostasis.  In  whatever  way  it  is  treated,  the  pedicle  is 
dropped  and  the  abdomen  is  closed. 

Vaginal  Hysterectomy  and  Myomectomy  for  Fibromyomata. — 
The  author  confesses  to  a  prejudice  against  and  a  limited 
experience  in  a  vaginal  hysterectomy  for  these  tumors.  The 
size  of  a  tumor  which  can  readily  be  delivered  by  vaginal  section 
scarcely  ever  warrants  radical  treatment  unless  there  is  necrosis 
or  malignant  degeneration.  If  it  is  necessary  to  resort  to 
morcellation  in  order  to  extract  the  tumor,  a  supravaginal 
amputation  is  an  easier  and  safer  operation. 

Cervical  myomata  which  are  easily  enucleated,  interstitial 
and  subperitoneal  growths  of  small  size  and  situated  in  the 
lower  uterine  walls  which  can  be  readily  enucleated  or  am- 
putated, are  naturally  well  suited  for  removal  by  the  vaginal 
route,  and  no  one  would  propose  any  other  method.  The 
removal  of  cervical  myomata  has  been  described.  For  the 
removal  of  corporeal  growths,  one  or  the  other  vaginal  vault  is 
opened  by  an  incision  around  the  cervix,  and  the  opening  is  en- 


350     Displacements  and  Diseases  of  the  Uterus 

larged  by  a  vertical  incision  in  the  median  Hne  of  the  vagina. 
The  peritoneal  reduplication  being  opened  as  is  done  in  vaginal 
hysterectomy,  the  growth  is  made  accessible  by  retroverting  or 
exaggeratedly  anteverting  the  uterus.  In  interstitial  and  non- 
pedunculated  tumors  the  capsule  is  incised  and  the  tumor,  pulled 
down  with  tenaculum  forceps,  is  enucleated  by  the  aid  of  a  fore- 
finger. If  the  growth  is  pedunculated,  its  pedicle  is  transfixed, 
ligated,  and  cut  off.  If  it  is  difficult  to  obliterate  the  bed  of  a 
tumor  which  has  been  enucleated,  the  cavity  is  packed  with  a 
strip  of  gauze  the  end  of  which  protrudes  through  the  vaginal 
vault.      Otherwise  the  vaginal  wounds  are  closed. 

If  morcellation    of   the   tumor   is   attempted,    the    following 


Fig.    347. — Morcellation  of  the  uterus  (Doyen). 

principles  must  be  remembered  :  Wedge-shaped  pieces  with  the 
bases  outward  are  exsected  by  a  knife  or  scissors  ;  before  the 
piece  is  removed  a  new  hold  of  the  tumor  or  the  uterus  mijst 
be  taken  farther  up,  otherwise  it  may  slip  up  into  the  pelvic 
cavity  and  become  inaccessible.  If  vaginal  hysterectomy  is  to 
be  performed  after  the  morcellation  of  the  tumor,  the  technic 
does  not  differ  materially  from  that  for  cancer  of  the  uterus, 
except  that  in  case  of  fibromyoma  bisection  of  the  uterus  at  least 
is  required,  and  morcellation  of  the  uterus  itself  is  usually  neces- 
sary, either  before  or  after  the  bisection,  as  may  be  most  con- 
venient.     Either  clamps  or  ligatures  may  be   used   to  secure  the 


The  Radical  Treatment  of  Fibromyomata       351 

broad  ligaments.  The  former  give  greater  security  against  hem- 
orrhage and  lessen  the  duration  of  the  operation,  but  increase 
the  danger  of  intestinal  obstruction  afterward  by  the  adhesion  of 
a  loop  of  bowel  to  the  broad  ligament  stumps.  The  latter  are 
more  difficult  and  tedious  to  apply,  are  more  likely  to  slip,  but 
permit  a  neat  closure  of  the  vaginal  wound  and  of  the  perito- 
neal cavity,  and  if  the  patient  escapes  the  danger  of  hemorrhage, 
insure  her  a  smoother  convalescence. 

A  word  in  conclusion  is  necessary  as  to  special  requirements 
in  the  removal  of  cystic  and  of  necrotic  tumors  by  the  abdominal 
route.  In  the  former,  the  large  size  which  the  tumor  attains  and 
its  fluctuating  feel  may  indicate  its  puncture  or  incision  ;  but  it 
should  be  remembered  that  probably  little  will  be  gained  in  this 
way,  and  the  partial  escape  of  the  tumor  contents  makes  the 
operation  less  clean  than  it  would  otherwise  be.  There  may, 
however,  be  one  large  cavity  which  can  be  immediately  evacu- 
ated, as  in  one  of  the  author's  cases.  The  removal  of  the  tumor 
is  governed  by  the  same  principles  that  obtain  in  the  removal 
of  other  fibroids.  Cystic  tumors  are  usually  pedunculated  and 
should  be  amputated  after  the  transfixion  and  ligation  of  the  pedicle. 
Enucleation  of  an  interstitial  fibrocystic  growth  is  usually  imprac- 
ticable. Anything  but  a  pedunculated  tumor  indicates  a  hysterec- 
tomy, and  the  former  may  also  require  the  removal  of  the  uterus 
on  account  of  the  vascularity  of  the  pedicle.  This  applies  particu- 
larly to  telangiectatic  growths.  If  the  tumor  is  necrotic,  care  must 
be  taken  not  to  leave  infected  tissue  within  the  pelvis.  A  pan- 
hysterectomy seems  the  most  logical  procedure  as  a  rule,  but 
the  author  has  successfully  twice  done  myomectomy  and  twice  a 
supravaginal  amputation  for  necrotic  and  infected  tumors  in  the 
puerperium. 

The  Lidications  for  a  Radical  Operation  in  Fibromyomata. — 
There  is  no  excuse  for  dogmatism,  prejudice,  or  self-interest  in 
deciding  this  important  question.  A  conscientious  surgeon,  who 
carefully  considers  his  patient's  interests  alone,  will  probably  not 
operate  in  much  more  than  20  per  cent,  of  his  cases.  Malignant 
degeneration,  telangiectasis,  cystic  degeneration,  and  necrosis  are 
positive  indications,  but,  as  Olshausen  points  out,  all  these  danger- 
ous degenerations  together  do  not  affect  more  than  5  per  cent,  of 
all  cases.  A  bleeding  that  is  reducing  the  woman  to  invalidism 
or  endangers  her  life,  and  that  is  not  controlled  by  palliative  treat- 
ment, indicates  an  operation.  Impaction  of  the  tumor  in  the 
pelvis,  with  pressure  symptoms  in  the  bowels  and  urinary  tract, 
may  demand  operation.  A  steady  growth  which  promises  the 
attainment  of  great  size  by  the  tumor  indicates  an  operation  before 
the  bulk  of  the  growth  becomes  excessive. 


352      Displacements  and   Diseases  of  the  Uterus 

The  patient's  circumstances,  age,  and  social  state  must  be 
considered.  If  invalidism  in  her  means  pauperism,  an  operation 
may  be  justifiable  that  would  not  be  so  in  a  woman  of  means,  able 
to  rest  and  spare  herself  as  much  as  possible.  If  the  patient  is 
a  single  woman  with  no  one  dependent  upon  her,  she  is  justified 
in  taking  a  risk  that  the  mother  of  a  family,  a  wage-earner  who 
supports  her  relatives,  or  the  nurse  of  an  invalid  parent  should 
avoid.  If  the  menopause  may  be  expected  shortly,  a  point 
might  be  strained  to  tide  a  woman  over  the  few  remaining 
months  or  years  until  the  bleeding  ceases  and  the  tumor  shrinks, 
although  it  must  be  remembered  that  in  exceptional  cases  con- 
tinued growth  or  degeneration  of  the  tumor  compels  a  resort  to 
operation  after  the  menopause.  If,  on  the  other  hand,  the  woman 
is  comparatively  young  and  must  look  forward  to  years  of  inva- 
lidism and  suffering,  she  may  prefer  the  operative  treatment,  and 
Jier  physician  is  justified  in  advising  it. 

Evidence  of  organic  disease  in  the  heart  or  kidneys  of  a  patient 
would  naturally  deter  the  surgeon  from  undertaking  a  capital  oper- 
ation, and  the  extreme  anemia  which  is  too  often  encountered  is  an 
unfavorable  factor.  A  hemoglobin  percentage  below  30  is  usu- 
ally considered  a  contraindication  to  anesthetization  and  a  capital 
operation  in  surgery,  but  the  gynecic  surgeon  must  occasionally 
operate  on  a  patient  with  but  10  per  cent,  of  hemoglobin.  In  one 
-of  the  worst  cases  in  the  last  category  to  recover  the  author  ever 
saw,  the  patient  was  as  energetically  supported  and  stimulated  as 
possible  in  the  two  weeks  which  commonly  intervened  between  the 
hemorrhages;  the  operation  was  undertaken  a  day  or  two  before 
the  expected  flow  and  a  submammary  injection  of  a  quart  of 
normal  salt  solution  was  given  just  before  anesthetization.  Her 
convalescence  could  not  have  been  more  satisfactory.  It  is  some- 
times necessary  to  undertake  an  operation  in  spite  of  kidney  or 
heart  disease.  The  longer  it  is  postponed,  the  worse  the  patient 
grows.  After  as  energetic  preparatory  treatment  as  possible, 
•elimination  for  the  kidneys,  stimulant  for  the  heart,  the  operation 
must  be  performed,  often  with  gratifying  success,  but  obviously 
with  a  higher  mortality  than  is  the  rule.  The  proportion  of 
operable  cases  will  naturally  increase  as  the  mortality  of  opera- 
tions for  fibromyomata  decreases.  At  present  it  is  a  fair  state- 
ment to  make  to  the  patient  and  her  family  that  the  mortality  of 
the  operation  is  about  5  per  cent.  It  is  less  than  that  in  favor- 
able cases.  But  allowing  for  cardiac  weakness  which  can  not  be 
foretold,  and  other  unforeseen  complications  and  accidents,  it  is 
better  to  avoid  the  reproach  of  having  induced  a  patient  to  con- 
sent to   operation  by  making  it  appear  less   dangerous  than   is 


Sarcoma  of  the  Uterus  353 

actually   the    case,   and   to    represent  the    danger   as    somewhat 
greater,  rather  than  as  somewhat  less,  than  the  truth. 

Sarcoma  of  the  uterus  may  affect  the  corporeal  and  cervical 
endometrium  or  the  uterine  wall.  The  last-named  variety  is  con- 
sidered here.  The  tumor  is  derived  from  the  intercellular  con- 
nective tissue,  the  adventitia  of  the  blood-vessels,  or  possibly 
from  the  conversion  of  muscle  into  sarcoma  cells.  Spindle- 
cell  are  four  times  more  frequent  than  round-cell  sarcomata. 
The  overwhelming  majority  of  cases  owe  their  origin  to  a  sar- 
comatous degeneration  of  a  fibromyoma.  The  statistics  of  A. 
Martin  and  von  Franque  ^  indicate  that  3  per  cent,  of  myomata 


Fig.  348. — Sarcoma  of  uterus  with  round  and  spindle  cells:  s.c,  Spindle  cells;   r.c, 
round  cells  (McConnell  and  J.  C.  Hirst). 

undergo  sarcomatous  degeneration.  This  estimate  is  generally 
regarded,  however,  as  too  high.  Sarcoma  of  the  uterus  is  a  rare 
growth.  Their  proportion  to  carcinomata  is  i  to  40  or  50.  A 
myosarcoma  does  not  necessarily  grow  very  rapidly ;  it  is  inclosed 
at  first  in  a  capsule  and  only  invades  surrounding  tissue  or  gives 
rise  to  metastases  late  in  its  history ;  it  has  often  been  spoken  of, 
therefore,  as  a  comparatively  benign  tumor,  which  is  not  correct. 
The  duration  of  life  is  about  that  of  cancer  of  the  uterus,  and 
metastases  occur  in  three-quarters  of  the  cases.  A  primary  sar- 
coma of  the  uterine  wall  is  usually  rapid  in  growth  and  has  an 
^  See  Gessner,  Veit's  "Handbuch  der  Gyn.,"  vol.  3^. 
23 


354     Displacements  and   Diseases  of  the  Uterus 

earl)'  fatal  termination.  It  is  prone  to  lymphangiectasis,  cystic 
degeneration,  and  necrosis.  Fatt}',  h}'aline,  and  myxomatous 
degenerations  are  also  noted. 

The  manner  of  growth  is  by  invasion  of  the  surrounding  myo- 
metrium, extension  into  the  pelvic  connective  tissue,  perforation 
of  the  perimetrium,  and  subsequent  involvement  by  contiguity  of 
the  intra-abdominal  structures.  There  is  frequently  a  submucous 
growth,  necrosis  of  the  tumor,  and  discharge  of  large  fragments 
through  the  os. 

A  curious  and  very  interesting  variety  of  uterine  sarcomata 
are  the  so-called  rccurroit  fibroids.  A  fibroid  polyp  may  be  re- 
mov^ed  repeatedly  from  the  uterus  and  only  after  the  sixth  or 
seventh  recurrence  present  the  microscopical  evidences  of  sar- 
coma. A  positive  diagnosis  of  sarcoma  of  the  uterine  wall  can 
only  be  made  by  the  microscopical  examination  of  the  tumor  after 
its  removal  or  of  pieces  discharged  by  the  os.  The  following 
clinical  evidence  should  always  excite  a  suspicion  of  sarcoma,  may 
justify  the  diagnosis,  and  may  indicate  hysterectomy  (Gessner): 

1.  If  a  tumor  regarded  as  a  myoma  fails  to  shrink  after  the 
menopause  and  continues  to  grow. 

2.  If  such  a  tumor  causes  a  return  of  hemorrhages  after  the 
menopause. 

3.  If  cachexia,  preceded  by  general  malaise,  appears,  associ- 
ated with  a  uterine  tumor. 

4.  If  a  uterine  tumor  causes  symptoms  of  ill  health  that  Can 
not  be  accounted  for  by  the  size  or  position  of  the  tumor. 

5.  If  ascites  develops  with  a  uterine  growth. 

6.  If  a  uterine  tumor  grows  very  rapidly  and  changes  markedly 
in  consistency  to  a  soft  and  friable  growth. 

7.  If  a  fibroid  polyp  recurs  after  its  removal. 

The  treatment  of  sarcoma  of  the  uterus .  is  complete  hys- 
terectomy by  the  vaginal  or  abdominal  routes  or  both. 

The  success  of  radical  treatment  has  not  been  very  encourag- 
ing. Recurrences,  metastases,  and  implantation  metastases  have 
occurred  in  a  large  proportion  of  the  small  number  of  recorded 
cases. 


PART  VII. 

DISEASES  OF  THE  ENDOMETRIUM;  DISORDERS  OF 
MENSTRUATION;  STERILITY. 

Endometritis. — The  anatomy  of  the  corporeal  endometrium 
and  its  differentiation  from  the  cervical  endometrium  have  been 
considered.  A  characteristic  important  to  remember  before 
studying  its  inflammation  is  its  freedom  in  a  state  of  health  from 
microbic  infection.  The  genital  canal  is  divided  into  normally 
infected  and  normally  sterile  regions.  The  boundary  line  be- 
tween the  two  is  the  external  os.  The  mucous  membrane  above 
that  point  contains  no  bacteria.  The  vaginal  mucous  membrane,- 
on  the  contrary,  is  the  habitat  of  Doderlein's  bacillus,  often  of  a 
yeast-fungus,  and  occasionally  of  pathogenic  germs,  usually  in 
a  state  of  diminished  virulence.  All  inflammations  of  the  endo- 
metrium may  be  broadly  divided  into  the  infectious  and  the  non- 
infectious. The  former  depend  upon  microbic  invasion  of  the 
endometrium.      They  are  : 

Septic  endometritis,  dependent  upon  pyogenic  cocci  and  the 
anaerobic  saprophytes.  This  disease  is  rare  except  after  abortion 
and  labor.  It  may  follow  operations  upon  the  cervix  and  the 
uterus  or  the  insertion  of  instruments  into  the  uterine  cavity. 
The  result  is  a  necrosis  of  the  superficial  endometrium  and  a 
granulation-cell  barrier  in  the  deeper  layers  of  the  mucosa, 
upon  which  the  woman  depends  for  her  safety.  Except  in 
a  puerpera  this  safeguard  is  almost  always  sufficient.  The 
necrotic  endometrium  is  exfoliated,  the  micro-organisms  perish 
in  a  struggle  for  existence  with  the  body-cells,  and  the  patient  is 
cured.  But,  as  often  happens  in  the  puerperium,  the  cocci  may 
penetrate  the  lymph-channels,  blood-spaces,  and  myometrium; 
localized  suppuration  in  the  uterine  wall,  peritonitis,  and  general 
infection  may  follow  with  the  likelihood  of  a  fatal  result.  The 
sapremic  endometritis  dependent  upon  microbic  decomposition  of 
putrescible  material  in  utero — sloughing  fibroids,  for  example — 
is  not  usually  followed  by  microbic  invasion  of  the  tissues,  but  a 
septic  intoxication,  possibly  fatal,  may  be  observed. 

Gonorrheal  endometritis  is  an  inflammation  of  the  mucous 
membrane  in  which  gonococci  are  found  in  and  under  the  epi- 
thelium, and  penetrating  the  myometrium   perhaps  to  the  peri- 

355 


;56 


Diseases  of  the  Endometrium 


metrium.      The  mucosa  is  much  thickened.      The  surface  epithe- 
hum  is  exfoHated  or  shows  a  transitional  stage  to  the  many-layered 


Fig.  349. — Normal  endometrium  of  corpus  uteri:  g,  Glands;   m,  myometrium;  s.e, 
surface  columnar  epithelium  (McConnell  and  J.  C.  Hirst). 


Fig.   350. — Tuberculosis  of  endometrium  (A.  E.  Roussel). 


squamous  type.     The  glands  are  unaltered  except  that  they  are 
di.stendcd    with    secretion,    and    the   cells    may   be   increased    in 


Syphilitic  Endometritis  357 

number.  Tliere  is  edema  and  a  round-cell  infiltration  of  the 
interglandular  tissue  with  a  few  pus-cells.  There  is  also  a  cellu- 
lar infiltration  of  the  myometrium,  which  may  lead  to  abscess 
formation  in  the  uterine  wall. 

Tuberculous  endometritis  is  not  primary,  but  secondary  to 
tuberculosis  of  the  tubes  or  cervix.  Three  forms  are  usually 
differentiated — miliary,  interstitial,  and  ulcerative.  Tubercle 
bacilli  are  the  infecting  agents,  but  their  presence  is  difficult  or 
impossible  to  demonstrate.  The  interior  of  the  uterus  may  be 
covered    with    a    caseous    material.      The  underlying    layer    of 


Fig.  351. — Tuberculosis  of  uterus:  /,  Tubercles  with  giant-cells;  m,  myometrium 
(McConnell  and  J.  C.  Hirst). 


surface  cells  is  unbroken.  Beneath  them  are  masses  of  epitheli- 
oid cells,  occasionally  giant-cells  or  round-cell  infiltration,  and 
possibly  typical  tubercles.  The  symptoms  are  leukorrhea  and 
metrorrhagia  with  the  associated  inflammation  of  the  tubes  or  of 
the  cervix.  The  curet  may  remove  caseous  material  and  endome- 
trium in  which  a  microscopical  examination  may  demonstrate  the 
nature  of  the  disease.  The  tuberculin  test  is  always  of  some 
value  in  suspected  tuberculosis  of  the  internal  organs. 

Syphilitic  endometritis  is  probably  the  same  as  the  syphilitic 
endometritis  gravidarum,  though  no  study  has  been  made  of  the 
condition  except  in  pregnant  women. 


358  Diseases  of  the  Endometrium 

Diphtheritic  endometritis  has  only  been  demonstrated  bacte- 
riologically  in  the  puerperium. 

Acute  infectious  endometritis  may  be  associated  with  the  infec- 
tious fevers,  as  cholera,  typhus,  the  exanthemata,  typhoid  fever, 
dysentery,  and  influenza,  in  which  there  is  an  intense  hyperemia, 
destruction  of  the  surface  epithelium,  blood  extravasations,  gland- 
ular hypertrophy,  and  round-cell  infiltration  of  the  interglandular 
connective  tissue. 

The  symptoms  of  infectious  endometritis  differ  in  the  various 
forms  noted  above.  Associated  with  the  infectious  fevers  a 
metrorrhagia  justifies  the  diagnosis.  The  same  symptom  is  the 
first  manifestation  of  syphilitic  and  possibly  of  tuberculous  endo- 
metritis, though  a  leukorrhea  is  more  frequent  in  the  latter  than 
hemorrhages.  Septic  endometritis  manifests  itself  by  a  sero- 
sanguinolent  and  later  a  purulent  discharge.  If  the  myome- 
trium is  involved,  there  is  pain,  but  not  otherwise.  Some  eleva- 
tion of  temperature  is  always  noted,  evanescent  if  the  attack  is 
mild,  but  persistent  and  alarming  if  the  myometrium  is  involved, 
if  the  lymph-channels  or  blood-spaces  are  infected,  and  if  the 
inflammation  spreads  to  the  peritoneum. 

Gonorrheal  endometritis  is  recognized  by  a  greenish-yellow 
purulent  discharge  from  the  os,  thin  in  consistency,  but  mingled 
with  masses  of  thick  ropy  mucopus  from  the  cervix.  In  a  fresh 
infection  it  is  easy  to  detect  gonococci  under  the  microscope  in  the 
discharge  gathered  from  the  cervix  on  a  pledget  of  cotton,  and 
there  are  the  S)'mptoms  of  specific  infection  of  the  urethra, 
Skene's  glands,  the  vulvovaginal  glands,  and  the  vagina.  There 
may  be  also  granular  vaginitis,  erosion  of  the  cervix,  and 
vulvitis.  In  chronic  cases  the  positive  diagnosis  is  difficult  or 
impossible.  Gonococci  may  be  undiscoverable.  It  has  been 
suggested  that  glycerole  of  tannin  tampons  be  placed  against  the 
cervix  and  left  in  position  for  six  hours,  the  discharge  collecting 
on  them  being  examined  for  gonococci,  but  even  this  plan  may 
not  succeed.  It  is  justifiable  to  make  a  presumptive  diagnosis  of 
gonorrheal  endometritis  if  there  is  always  a  rope  of  thick 
mucopus  hanging  out  of  the  cervix,  a  persistent  mucopurulent 
leukorrhea  resisting  treatment,  an  exacerbation  of  the  discharge 
following  alcoholic  or  sexual  excess,  fatigue  or  cold,  and  a  men- 
orrhagia  in  the  form  of  prolonged  rather  than  profuse  menstrua- 
tion with  decreased  intermenstrual  intervals.  A  tubo-ovarian 
inflammation,  if  it  exists,  strengthens  the  suspicion  of  specific 
infection. 

The  treatment  of  infectious  endometritis  differs  with  the  variet}^ 
Tuberculosis  indicates  hysterectomy  if  there  is  no  tuberculous 
lesion  in  other  important  organs  and  if  the  disease  can  be  elimi- 


Acute   Infectious   Endometritis  359 

natecl  by  the  renio\-al  of  the  uterus  and  its  appendages.  Syph- 
ihtic  endometritis  calls  for  mercury  and  iodid  of  potassium  and  a 
ciu-ettage  if  the  menorrhagia  persists  after  the  patient  is  brought 
under  the  influence  of  the  antisyphilitic  remedies.  Septic 
endometritis,  if  mild  and  evanescent,  demands  no  local  treatment, 
except  the  ice-coil  or  an  ice-bag  on  the  hypogastrium  and  rest 
in  bed.  Grax'er  cases  call  for  irrigation  of  the  uterine  cavity  by 
sterile  water  douches  through  a  two-way  catheter  and  a  gentle 
curettage  of  the  uterus  with  a  dull  curet  and  the  curetment 
forceps  to  remove  the  necrotic  endometrium  without  penetrat- 
ing the  new-formed  granulation  layer  under  the  infected  mucosa. 

Tlie  trcatinoit  of  gonorrlieal  endometritis  demands  the  exer- 
cise of  good  judgment  and  the  careful  study  of  the  individual 
case.  The  object  should  be  to  prevent,  if  possible,  the  extension 
of  infection  from  the  \agina  to  the  cervix  and  endometrium  by 
the  energetic  and  early  treatment  of  specific  vulvitis  and  vaginitis 
(page  138).  The  premature  resort  to  intra-uterine  treatment  may 
carry  gonococci  into  the  uterus.  If  intra-uterine  infection  occurs, 
as  it  probably  will  in  spite  of  every  effort  to  prevent  it,  the 
attempt  should  be  made  to  destroy  the  gonococci  lodged  in  the 
endometrium  before  they  invade  the  tubal  canals  whence  they  can 
only  be  removed  perhaps  by  salpingectomy. 

After  a  thorough  vaginal  disinfection,  by  tincture  of  green 
soap,  hot  w^ater,  and  pledgets  of  cotton,  followed  by  a  perman- 
ganate of  potassium  douche  (foj  saturated  solution  to  Oij),  the 
cervical  canal  is  wiped  out  by  a  pledget  of  dry  cotton  on  an 
applicator  to  remove  the  tenacious  plug  of  infected  mucus. 
This  is  followed  by  the  application  to  the  cervical  endometrium 
of  a  20  per  cent,  solution  of  argyrol  on  a  pledget  of  cotton, 
which  is  allowed  to  remain  in  the  cervix  for  five  minutes. 
Then  a  Fritsch's  intra-uterine  catheter,  previously  boiled,  is 
passed  into  the  uterine  cavity,  which  is  irrigated  b\'  the  perman- 
ganate of  potassium  solution.  Following  the  irrigation  an 
application  of  the  argyrol  solution  is  made  to  the  corporeal 
endometrium.  This  treatment  is  repeated  daily  until  the  uterine 
discharge  becomes  normal.  A  week  or  more  may  be  required. 
In  spite  of  apparent  success,  the  slow  development  of  a  pyo- 
salpinx  may  be  obsen^ed  later.  Curettage  is  contraindicated  in 
acute  gonorrheal  endometritis.  If  the  gonorrheal  endometritis 
has  become  chronic,  in  which  stage  the  physician  most  often  sees 
it,  there  is  no  treatment  which  promises  such  speedy  and  sure 
relief  as  a  dilatation  of  the  cervix,  a  thorough  curettage,  and  the 
application  to  the  curetted  surface  of  pure  carbolic  acid  intro- 
duced by  an  applicator  on  a  pledget  of  cotton.  This  treatment 
is  contraindicated  if  there  is  coincident  tubo-ovarian  inflammation. 


o 


60  Diseases  of  the  Endometrium 


unless  it  is  followed,  as  it  should  be,  by  an  immediate  abdominal 
section  to  deal  with  the  pelvic  inflammatory  condition,  or  is  per- 
formed in  a  well-equipped  clinic  with  the  understanding  that  an 
abdominal  section  may  be  required  at  any  time  during  the  conva- 
lescence from  the  curettage.  If  for  any  reason  the  latter  opera- 
tion is  inadvisable  oris  refused,  local  treatment  of  the  endometrium 
may  be  attempted,  but  it  is  uncertain,  tedious,  often  painful,  and 
not  without  risk.  Applications  of  argyrol,  of  nitrate  of  silver  solu- 
tion, of  iodin,  carbolic  acid,  carbolic  acid  and  glycerin,  and  of 
weak  solutions  of  chlorid  of  zinc;  the  insertion  of  medicated 
bougies  containing  argentum  Crede,  protargol,  argyrol,  and  other 


Fig.    352. — Chronic  hyperplastic   glandular  endometritis:    eg.    Convoluted  glands; 
d.g,  dilated  glands  (McConnell  and  J.  C.  Hirst). 

astringents  and  antiseptics ;  intra-uterine  irrigations  of  formalin, 
I  :  6000,  of  permanganate  of  potassium,  and  of  sublimate  solu- 
tions are  the  best  remedies.  Any  intra-uterine  treatment  should 
be  preceded  by  an  irrigation  of  Oij  of  boracic  acid  solution,  gr.  x 
to  foj,  to  wash  away  the  mucous  discharge  bathing  the  endo- 
metrium and  to  allow  the  remedies  employed  to  reach  the  diseased 
surfaces. 

It  may  be  easy  to  cure  the  gonorrhea  of  the  corporeal  en- 
dometrium;  it  is  almost  impossible  to  reach  gonococci  lurking  in 
the  deep  cervical  glands.  The  woman  may  never  be  rid  of  a 
mucopurulent  leukorrhea,  more  or  less  infectious,  until  a  high 
amputation  of  the  cervix  is  performed. 


Chronic   Hyperplastic  Endometritis 


361 


Chronic  hyperplastic  endometritis  does  not  depend  upon  micro- 
bic  infection,  though  the  ultimate  stage  of  an  infectious  endome- 
tritis may  be  chronic  congestion  and  hyperplasia,  so  that  infection 
ma)' possibly  be  the  starting-point  of  the  chronic  disease.  Much 
more  frequently  the  cause  is  found  in  a  condition  determining  an 
oversupply  of  blood  to  the  uterus.  These  conditions  are  so 
numerous  that  hyperplastic  endometritis  is  by  far  the  commonest 
disease  of  women.  Displacement  of  the  uterus  ;  subinvolution  ; 
injuries  and  diseases  of  the  cervix;  persistence  of  decidual  cells 
(deciduoma)  in  the  endometrium  ;  tight  lacing  ;  violation  of  the 
laws    of   sexual   hygiene  ;    obstruction   to  the  pelvic   circulation 


Fig.    353. — Chronic   interstitial  endometritis:   ^.5,  Gland-spaces ;  s,    stroma,   greatly 
hypertrophied  (McConnell  and  J.  C.  Hirst). 


by  pelvic  and  abdominal  tumors,  especially  those  projecting  from 
the  uterine  wall  into  the  uterine  cavity ;  by  heart  and  liver 
disease,  and  by  constipation ;  overexertion  in  the  erect  pos- 
ture ;  stenosis  of  the  cervix,  dysmenorrhea,  and  a  consequent 
irritation  of  the  endometrium,  and  nervous  excitation  are  some 
of  the  conditions  that  cause  a  chronic  uterine  congestion  and  a 
hyperplasia  of  the  endometrium.  The  hyperplasia  may  affect 
the  glandular  or  interstitial  structures,  or  both.  In  hypertrophic 
glandular  endometritis  the  glands  are  increased  in  number,  ac- 
quire a  corkscrew  form,  and  display  a  dilatation  of  the  gland- 
spaces,  with  excrescences  of  epithelium  in  their  lumen.  There  is 
also  a  proliferation  of  epithelium  upon  the  surface  of  the  endome- 


o 


62  Diseases  of  the  Endometrium 


trium,  but  nowhere  a  duplication  of  the  single  epithelial  layer  in 
the  glands  or  on  the  surface,  except  in  elderly  women.  In  the  in- 
terstitial form  there  is  at  first  a  round-cell  infiltration  of  the  inter- 
glandular  connective  tissue.  The  glands  are  widely  separated  and 
compressed  ;  there  may  be  exfoliation  of  the  surface  epithelium. 
In  the  later  or  chronic  stage  the  round  cells  are  converted  into 
spindle  cells;  scar  tissue  is  formed  ;  the  glands  are  so  compressed 
that  they  atrophy  and  disappear  ;  the  uterine  mucosa  is  reduced 
to  a  single  layer  of  epithelial  cells  on  the  surface  of  the  uterine 
cavity  (atrophic  endometritis).  There  is  frequently  a  mixed  form 
of  interstitial  and  glandular  endometritis,  and  varying  gradations 


rig.    354. — Atrophic  endometritis,    showing    complete  disappearance  of  glands:    e, 
Remnant  of  endometrium  ;  m,  myometrium  (McConnell  and  J.  C.  Hirst). 

may  be  observed  between  the  purely  glandular  and  the  interstitial 
hypertrophy. 

A  curious  anomaly  rarely  observed  on  the  surface  of  cervical 
polyps  and  even  over  the  whole  corporeal  endometrium  is  the 
conversion  of  the  columnar  epithelium  into  many-layered  squa- 
mous epithelium  (psoriasis  uteri). 

Another  rarity  in  the  histology  of  endometritis  is  the  per- 
si.stence  of  islands  of  decidual  cells  after  abortion,  surrounded  by 
layers  of  granulation-cell  infiltration  (deciduoma). 

The  symptoms  of  chronic  endometritis  are  menorrhagia,  met- 
rorrhagia, and  leul-corrhea.  Ordinarily  there  is  a  profuse,  pro- 
longed menstruation  with  shortened  intermenstrual  interval.      In 


Treatment  of  Chronic  Endometritis  363 

exceptional  cases  there  is  a  continuous  bloody  discharge,  worse 
at  inter\'als  corrtsponding  to  the  menstrual  periods,  or  in  conse- 
quence of  physical  effort  or  nervous  excitement,  which  so  reduces 
the  patient  that  she  becomes  as  anemic  as  the  subject  of  a  fibroid 
tumor  or  cancer  of  the  cervix.  ^  Leukorrhea  is  commonly  ob- 
served in  the  intermenstrual  periods,  the  discharge  coming  mainly 
from  the  cervical  glands  in  the  shape  of  thick  ropy  mucus, 
though  the  corporeal  endometrium  may  contribute  a  thin  sero- 
sanguinolent  discharge.  There  is  often  noted  an  exacerbation  or 
the  appearance  of  a  leukorrhea  midway  between  the  menstrual 
periods.  This  discharge  may  be  tinged  with  blood  or  may  be 
entirely  hemorrhagic.  Usually  there  is  no  pain  with  endome- 
tritis, but  rarely  the  appearance  of  the  intermenstrual  discharge 
is  regularly  associated  with  severe  pain.  The  intermenstrual 
pain  to  which  Priestly  first  called  attention,  or  the  "  Mittelschmerz" 
of  the  Germans,  is  difficult  to  explain.  It  has  been  attributed  to 
the  first  onset  of  the  premenstrual  congestion  which  is  supposed 
to  begin  at  this  time  and  to  the  nervous  excitation  which  accom- 
panies it.  As  there  is  nev^er  an  endometritis  without  some  degree 
of  metritis,  a  bimanual  examination  reveals  the  increased  size 
and  weight  of  the  uterus  and  changes  in  its  consistency.  It  is 
softer  than  normal  if  the  congestion  is  of  comparatively  recent 
origin,  hard  perhaps  as  stone  in  the  ultimate  stages  of  the  dis- 
ease. The  physical  examination  should  always  take  into  account 
the  possible  causes  of  uterine  congestion,  which  may  be  detected 
in  a  vaginal  or  abdominal  examination. 

The  treatment  of  chronic  endometritis  is  a  dilatation  of  the 
cervical  canal,  a  thorough  curettage,  and  at  the  same  time  the 
removal  of  the  cause  of  uterine  congestion.  Neglect  of  the 
last-named  precaution  makes  the  success  of  treatment  doubtful 
or  impossible.  Hence  a  curettage  must  often  be  combined  with 
repairs  of  the  injuries  of  childbirth,  correction  of  uterine  dis- 
placements, the  surgical  treatment  of  pelvic  inflammatory  disease, 
and  the  removal  of  tumors  from  the  uterus,  the  uterine  cavity, 
the  cervix,  and  the  pelvis  or  abdomen.  Constipation  must  be  com- 
bated, a  weak  circulation  may  demand  systematic  rest  or  digitalis. 
Gymnastic  exercises  or  open-air  sports  may  be  indicated  to  give 
tone  to  the  whole  muscular  system  as  well  as  to  that  of  the  circula- 
tory apparatus.  Eftbrts  to  prevent  conception,  and  other  violations 
of  the  laws  of  sexual  hygiene  should  be  forbidden.  It  may  be 
necessary  to  take  an  ambitious  school-girl  from  her  studies  or  to 
remove  a  cause  of  mental  activity  or  nervous  strain. 

'  The  author  has  seen  six  young  girls  under  fourteen  years  of  age  whose  men- 
struation began  and  continued  as  a  profuse  metrorrhagia  for  months  until  curettage  re- 
lieved them.      In  five  there  was  glandular,  in  one  interstitial  endometritis. 


364  Diseases  of  the  Endometrium 

Medicinal  treatment  may  be  required  in  addition  to  the 
curettage  or  in  place  of  it.  A  combination  of  hydrastinin, 
ergotin,  and  stypticin  is  the  most  efficient  astringent  remedy. 
Suprarenal  extract  (3-grain  tablets)  comes  next  in  efficiency.  ^ 
Gelatin  hypodermatically,  15  c.c.  of  a  10  per  cent,  solution 
in  sterile  normal  salt  solution,  or  by  the  mouth  is  worth  a  trial. 
Local  applications  to  check  uterine  hemorrhages  are  very 
properly  in  disfavor  and  are  falling  into  disuse.  The  uncer- 
tainty of  results  and  the  dangers  of  their  use  make  it  almost 
unwarrantable  to  recommend  them.  Intra-uterine  applications 
of  astringents  and  styptics  may  be  occasionally  employed  by  the 
expert  specialist  with  all  the  care  and  caution  that  their  use  de- 
mands, but  they  are  not  to  be  resorted  to  routinely  by  the  general 
practitioner.  Hot- water  vaginal .  douches  (a  gallon  at  115°— 
1 20°  F.)  and  glycerin  tampons  reduce  a  temporary  congestion, 
but  they  can  not  be  expected  to  relieve  permanently  a  chronic 
hyperplastic  endometritis. 

The  endometrium  removed  by  the  curet  should  always  be 
carefully  observed  both  macroscopically  and  microscopically.  To 
the  naked  eye  it  is  soft,  thick,  dark  red  in  color,  and  infiltrated 
with  blood.  Whitish  villosities  are  numerously  scattered  through 
it  looking  like  grains  of  sago  or  tapioca.  This  is  the  common 
"fungous  endometritis"  or  the  hypertrophic  glandular  form.  In 
the  interstitial  variety  the  curet  may  remove  a  very  small 
quantity  of  thin  ribbon-like  stripes  of  membrane.  Under  the 
microscope  are  seen  the  characteristic  appearances  of  the  two 
forms  of  endometritis  already  described. 

Werth's^  observations  of  five  uteri  extirpated  at  various 
periods  after  the  removal  of  the  mucosa  by  a  curet  indicate  that 
the  endometrium  is  restored  from  the  depths  of  the  utricular 
glands  within  five  days  after  a  curettage.  An  obliteration  of  the 
uterine  cavity  wholly  or  in  part  has  been  noted  four  times  after 
curettage  in  the  puerperium  (Doderlein).  Such  a  result  might  be 
possible  after  too  vigorous  a  use  of  the  curet  in  the  non-puerperal 
uterus. 

Neoplasms  of  the  Endometrium. — Adenocarcinoma  of  the 
endometrium  may  have  its  origin  in  the  surface  epithelium,  the 
glandular  epithelium,  or  in  a  fibro-adenomatous  polyp.  The 
growth  is  at  first  isolated,  usually  extending  into  the  cavity  of  the 
uterus,  sending  out  numerous  fine  finger-like  processes,  and  pos- 
sessing, therefore,  a  papillomatous  character,  or  later  forming  a 

lit  is  said  to  be  a  common  practice  among  prostitutes  to  take  indigo  in  order 
to  prevent  the  appearance  of  menstruation  when  it  might  interfere  with  their  trade. 
The  action  of  this  substance  as  a  uterine  hemostatic  deserves  more  attention  than  it 
has  received. 

2"  Arch.  f.  Gyn.,"  Bd.  xlix,  H.  3. 


Adenocarcinoma  of  the  Endometrium 


365 


large,  dome-shaped  mass,  soft  in  consistency  and  prone  to  nec- 
rosis.    A  growth  beginning  within  the  gland   may  extend  into 


Fig.  355- — Adenocarcinoma  of  uterus  :  e,  Enormously  hypertrophied  epithelium 
lining  glands ;  w,  myometrium,  somewhat  infiltrated  by  cancer-cells  ;  /,  lumen  of 
gland  (McConnell  and  J.  C.  Hirst). 


Fig.   356. — Adenocarcinoma  of  endometrium. 


the  myometrium,  even  to  the  perimetrium,  under  which  may  be 
seen  yellowish-white  soft  lumps. 


;66 


Diseases  of  the  Endometrium 


On  the  surface  of  the  endometrium  there  is  a  multiplication  of 
the  epithelial  layer,  and  numerous  fine  finger-like  excrescences, 
consisting  at  first  mainly  of  epithelium,  later  provided  with  a 
stroma.  These  processes  send  out  branches  and  everywhere  is 
seen  an  exaggerated  hyperplasia  of  the  epithelium.  The  nuclei  of 
the  cells  are  gradually  increased  in  size,  become  irregular  in  out- 
line, staining  intensely.  The  glands  are  enlarged;  numerous 
offshoots  of  new  glands  are  seen,  irregular  in  arrangement  and 
lined  with  many  layers  of  epithelium  instead  of  the  normal  single 
la\-er.  The  basement  membrane  is  penetrated  and  the  glands 
communicate.       The    gland-spaces   are    dilated,   containing  des- 


Fig.   357. — Adenocarcinoma  of  endometrium. 

quamated  epithelial  cells,  pol}'morphonuclear  leukocytes,  and 
detritus. 

The  later  stage  of  this  form  of  cancer  is  ulcerative  and  necrotic, 
large  crater-like  pits  developing  in  the  myometrium,  perforating 
the  uterus,  involving  by  contiguity  the  intestines,  omentum,  and 
peritoneum,  by  extension  along  the  lymphatic  ducts  the  iliac, 
lumbar,  and  even  the  inguinal  lymphatic  glands,  and  by  metas- 
tases or  extension  the  tubes  and  ovaries,  liver,  spleen,  lungs,  and 
other  structures;  but  involvement  of  the  lymphatics  is  the  excep- 
tion, as  in  the  case  of  cervical  cancer,  and  for  the  same  reason  ; 
metastases  are  also   late  in  occurrence  and  exceptional. 

The  commonest  age  for  the  development  of  an  adenocarcinoma 
is  between  fifty  and  sixty,  but  it  may  be  found  in  women  at  and 
under  thirty,  or  in  extreme  old  age.      Child-bearing  has  no  part 


Adenocarcinoma  of  the  Endometrium 


;67 


in  the  predisposition  to  this  form  of  cancer.  The  majority  of  the 
author's  cases  have  occurred  in  single  or  sterile  women.  One  is 
struck  with  the  frequent  association  of  myoma  and  adenocarcinoma 
of  the  corpus  uteri,  but  the  former  probably  has  no  part  in  a  pre- 
disposition to  the  latter.     A  large  proportion  of  elderly  women 


Fig.    358. — Adenocarcinoma  of  endometrium  and  subperitoneal  fibroma. 


Fig.  359. — Malignant  adenoma  of  uterus:  g.s,  Glands  penetrating  deeply  into 
myometrium;  /'.v,  blood-vessel;  t,  cancer-cell  infiltration  of  myometrium  (McCon- 
nell  and  J.  C.  Hirst). 


have  uterine  myomata,  hence  they  are  frequently  found  associated 
with  a  disease  of  advanced  age.  The  myoma,  if  it  exists,  is  rarely 
invaded  by  the  carcinoma.  Inclosed  in  a  capsule,  poorly  nourished, 
and  possessing,  as  a  rule,  no  epithelial  structures,  it  offers  an 
unfavorable  field  for  the  invasion  of  a  cancer.     It  is  possible,  how- 


o 


68  Diseases  of  the  Endometrium 


ever,  as  already  pointed  out,  for  an  adenomyoma  to  be  the  start- 
ing-point of  an  adenocarcinoma. 

There  may  be  a  malignant  adenoma  of  the  corporeal  en- 
dometrium as  well  as  of  the  cervix  (Fig.  359).  Clinically  there 
is  no  distinction  to  be  made  between  this  growth  and  adeno- 
carcinoma. 

SyuiptoDis  and  Diagnosis. — The  first  symptom  to  attract 
attention  is  a  serosanguinolent  discharge.  If  this  discharge 
appears  after  the  menopause,  with  a  healthy  condition  of  the 
cei'vix,  it  is  strongly  suggestive  of  adenocarcinoma  of  the  cor- 
poreal endometrium.  Practically  the  only  other  explanation  is 
a  benign  intra-uterine  polyp.  ^  The  bloody  discharge  is  at 
first  irregular  and  intermittent  and  is  not  foul.  Later  the 
bleeding  becomes  almost  or  quite  continuous,  with  exacerba- 
tions, and  is  foul  smelling.  Hemorrhage  is  rarely  so  severe 
as  it  is  in  cancer  of  the  cervix.  The  uterus  is  always  dis- 
tinctly enlarged,  except  in  the  early  stages.  The  increase  in 
size  may  be  considerable.  Pain  is  by  no  means  a  constant 
symptom.  It  is  usually  absent  until  the  later  stages  of  the  growth. 
The  general  health  may  not  be  affected  for  many  months  and 
there  may  be  no  loss  of  weight.  In  some  cases,  on  the  contrary, 
there  is  an  early  appearance  of  cachexia,  a  marked  decrease  in 
weight,  and  general  malaise.  The  positive  diagnosis  can  only  be 
made  by  a  microscopical  examination  of  the  scrapings  removed 
by  a  curet.  It  should  be  a  rule  of  practice  to  have  uterine  scrap- 
ings examined  after  every  curettage  whether  cancer  is  suspected 
or  not.  If  there  is  reason  to  apprehend  a  malignant  growth  of 
the  endometrium,  it  is  possible  to  remove  sufficient  material  for 
diagnostic  purposes  in  an  office  visit  by  the  smallest  size  Sims' 
curet;  but  the  preferable  plan  by  far  is  to  carry  out  a  formal 
curettage  under  anesthesia,  removing  all  the  endometrium  and 
subjecting  it  to  microscopical  examination.  A  rapid  diagnosis 
by  the  freezing  process  is  practicable,  so  that  on  receiving  an  un- 
favorable report  the  surgeon  may  at  once  proceed  to  a  radical 
operation  ;  but  the  better  plan  is  to  give  the  pathologist  time  for 
a  careful  study  of  the  specimens,  embedded  in  celloidin.  Three 
or  four  days  to  a  week  should  be  allowed  between  the  explora- 
tory curettage  and  the  radical  operation,  if  the  latter  is  indicated. 
It  is  often  possible  to  be  morally  sure  of  the  malignancy  of  a 
specimen  removed  by  the  curet  on  its  macroscopical  appearance. 
A  thick,  whitish,  fleshy  mass,  quite  different  in  appearance  and 
feel  from  the  thickest  hypertrophied  endometrium,  from  pieces  of 

1  The  author  has  reported  two  cases  of  metrorrhagia  beginning  years  after  the 
menopause,  due  to  benign  mucous  polyps  in  the  uterine  cavity.  "  Therapeutic 
Gazette,"   Oct.  15,  1901. 


Adenocarcinoma  of  the  Endometrium  369 

placenta  or  decidua  retained  in  ntcro  or  from  mucous  polyps  has 
often  enabled  the  author  to  anticipate  the  pathologist's  report  ; 
but  one  is  never  justified  in  resorting  to  a  radical  operation 
without  a  positive  diagnosis  of  malignancy  from  the  microscopist. 
If  there  is  a  doubtful  or  uncertain  report,  there  should  be  a  sec- 
ond curettage  six  weeks  after  the  first  and  another  microscopical 
examination  of  the  scrapings. 

Trcatincnt. — There  is  but  one  treatment  of  adenocarcinoma 
of  the  endometrium — panhysterectomy.  If  the  disease  is  detected 
in  its  very  incipiency,  a  thorough  curettage  has  been  known  to 
effect  a  permanent  cure;^  but  the  disease  when  it  first  comes 
under  medical  observation  is  almost  alwa}'s  so  far  advanced  that 
radical  treatment  alone  should  be  considered. 

If  the  vagina  is  capacious,  a  combined  hysterectomy  is  the 
most  satisfactory,  beginning  b}'  the  vagina  and  ending  by  the 
abdomen,  as  in  carcinoma  of  the  cervix.  If  the  patient  is  a  sin- 
gle woman  with  a  narrow  vagina,  the  abdominal  operation  alone 
is  the  most  convenient.  The  author  finds  himself  less  inclined 
with  every  year  to  trust  to  vaginal  hysterectomy  alone.  It  is 
impossible  by  this  route  alwa}'s  to  remove  the  appendages,  the 
broad  ligaments,  and  the  parametrium  as  thoroughly  as  they 
should  be  remo\'ed,  and  it  is,  of  course,  impossible  to  investigate 
the  condition  of  the  iliac  and  the  lumbar  lymphatic  glands  except 
by  an  abdominal  operation.  It  is  true  that  these  glands  are  only 
exceptionally  involved,  and  only  as  a  rule  in  inoperable  cases,  but 
they  should  always  be  examined,  and  if  there  is  any  abnormality  in 
their  size  and  consistency  they  should  be  removed  by  slitting  the 
peritoneum  over  them  on  a  grooved  director  and  carefully  dis- 
secting them  out  without  injury  to  the  important  vessels  near  and 
on  which  they  rest.  In  many  a  case  so  treated  the  enlarged 
gland  will  not  be  found  cancerous,  but  enlarged  and  hardened 
by  inflammation.  In  a  few  cases  in  which  the  author  has 
removed  cancerous  iliac  glands  the  condition  was  really  inope- 
rable. There  were  recurrence  and  metastasis  in  a  short  time. 
Nevertheless,  an  occasional  success  may  be  secured  by  the 
removal  of  the  glands  in  a  case  that  would  be  doomed  to  cer- 
tain failure  if  these  glands  already  cancerous  w^ere  overlooked  and 
allowed  to  remain. 

^  The  author  has  had  such  a  case.  A  woman  who  had  had  metrorrhagia  for 
some  years  with  an  enlarged  uterus  was  subjected  to  a  thorough  curettage.  The  speci- 
mens, which  looked  suspicious,  were  submitted  to  H.  L.  Williams  and  H.  D.  Beyea. 
They  both  reported  independently  that  they  found  an  incipient  adenocarcinoma,  but 
the  disease  was  in  such  an  early  stage  that  a  subsequent  curettage  with  another  exam- 
ination of  the  degenerated  endometrium  was  desirable.  Six  weeks  later  the  uterus 
was  again  scraped  under  anesthesia.  The  scrapings  this  time  had  no  trace  of  malig- 
nancy. The  woman  at  present,  four  years  later,  remains  well. 
24 


Tf^o  Diseases  of  the  Endometrium 

The  prog)iosis  of  the  operative  treatment  is  good.  The  hys- 
terectomy is  easier  and  safer  than  the  same  operation  for  cervical 
cancer,  and  there  is  a  recurrence  in  only  one-fifth  to  one-third  of 
the  cases. 

Sarcoma  of  the  endometrium  arises  usually  from  the  deeper 
interglandular  connective  tissue,  possibly  from  the  blood-vessel 
walls,  and  very  rarely  from  the  lymphatics  (lymphosarcoma). 
The  growth  assumes  a  diffuse  or  a  polypoid  form.  The  former 
is  circumscribed,  sessile,  and  projects  into  the  uterine  cavity  as 
an  irregularly  lobulated  tumor.  The  latter  is  pedunculated. 
Gessner  ^  has  collected  130  cases  of  sarcoma  of  the  corporeal 
endometrium — 81  polypoid,  49  diffuse.  The  growth  is  usually 
toward  the  uterine  cavity.  The  myometrium  is  slowly  invaded 
and  only  late  in  the  disease.  Ultimately  the  uterine  wall  is  per- 
forated and  the  intra-abdominal  organs  are  involved.  Metastases 
are  exceptional,  and  if  they  occur  are  seen  toward  the  end  of  the 
individual's  life.  There  is  little  tendency  to  extension  of  the 
growth  toward  the  cervix  or  into  the  vagina,  and  very  slight 
inclination  to  invade  the  bladder  and  rectum,  which  are  so  com- 
monly involved  in  cancer  of  the  uterus. 

In  the  diffuse  form  the  endometrium  over  the  growth  is 
destroyed  early ;  in  the  polypoid  form  it  is  preserved  in  a  normal 
condition  until  late.  The  remaining  endometrium  may  be  unal- 
tered, may  be  the  seat  of  hyperplastic  glandular  and  interstitial 
endometritis,  may  become  atrophic,  or  be  converted  into  granula- 
tion tissue. 

The  blood-supply  may  be  scanty.  On  the  contrary,  it  is 
sometimes  so  rich  that  the  tumor  is  telangiectatic.  There  is  a 
strong  tendency  to  necrosis  of  the  soft  mass  of  the  turnor,  large 
pieces  of  which  may  be  expelled  from  the  uterus.  Cystic  and 
myxomatous  degenerations  are  occasionally  noted.  The  sarcoma 
is  almost  always  a  mixed  round-cell  and  spindle-cell  growth,  one 
kind  of  cell  perhaps  predominating  over  the  other.  Giant-cells 
on  a  careful  examination  are  discovered  in  a  considerable  pro- 
portion of  the  cases.  They  were  present  in  all  of  Whitridge 
Williams'  (3)  and  in  one-fifth  of  Gessner's  (5)  cases.  Angio- 
sarcoma, cystosarcoma,  melanosarcoma,  and  chondrosarcoma 
have  been  observed  in  sarcoma  of  the  corporeal  endometrium. 
The  occurrence  of  adenosarcoma  and  carcinosarcoma  is  doubtful 
and  has  not  been  demonstrated. 

Symptoms  and  Diagnosis. — Sarcoma  of  the  endometrium  is  a 
disease  of  old  age  in  the  majority  of  cases,  but  it  may  occur  at 
any  time  from  early  infancy.  Child-bearing  plays  no  part  in  the 
etiology,  nor  does  heredity.      The  uterus  may  not  be  enlarged  at 

1  Veit's  "  Handbuch,"  vol.  3  -. 


PLATE  12. 


-^ 


^c^ 


^ 


A 


Sarcomatous  degeneration  of  a  fibro-adenomatous  polyp  of  the  corporeal  endometrium. 


Sarcoma  of  the  Endometrium 


371 


first,  but  with  the  increase  in  the  size  of  the  tumor  there  is  neces- 
sarily an  enlargement  of  the  uterus.  Occlusion  of  the  cervix  and 
hematometra  are  frequently  noted.  The  accumulation  of  bloody 
fluid  has  been  enormous.  Fifteen  liters  have  been  evacuated. 
In  such  a  case  the  uterus  is  a  cystic  tumor  reaching  to  the 
ribs.  Pyometra  is  not  so  common  and  the  distention  is  not  so 
ereat. 


Fig.   360. — Myxomatous  polyp  of  corporeal  endometrium.      Polyp  turned  out,  show- 
ing very  slender  pedicle  attached  to  left  cornu. 


Pain  is  not  a  prominent  symptom  until  the  myometrium  and 
the  perimetrium  are  involved.  When  pain  is  present,  its  occur- 
rence at  regular  intervals  has  been  noted. 

Inversion  of  the  uterus  is  frequent  in  the  polypoid  form. 

There  is  observed  with  great  regularity  a  profuse  serous  leu- 
korrhea,  at  first  odorless,  later  foul.  A  bloody  discharge  suc- 
ceeds the  leukorrhea  or  accompanies  it.      These  symptoms  after 


3/2  Diseases  of  the  Endometrium 

the  menopause  are  ahvays  suspicious.  Owing  to  the  rapid  necro- 
sis of  the  tumor,  large  pieces  of  necrotic  tissue  may  be  expelled 
from  the  cervix,  the  microscopical  examination  of  which  may 
determine  the  nature  of  the  tumor;  but  they  may  be  so  disor- 
ganized as  to  be  valueless  for  diagnostic  purposes.  Although 
the  bladder  is  very  rarely  involved,  vesical  tenesmus  is  often 
observed. 

The  average  duration  of  the  disease  is  two  years,  but  it  varies 
from  a  few  months  to  five  years. 

The  diagnosis  can  only  be  made  by  the  microscopical  exam- 


Fig.    361. — Adenomyxomatous    polyp    of   corpus     uteri:    f.t,    Fibrous    tissue;   g.s, 
gland-spaces,  dilated;   eg,  corkscrew  gland  (McConnell  and  J.  C.  Hirst). 

ination  of  tissue  removed  from  the  uterus  by  a  curet  or  a  curet- 
ment  forceps. 

The  treatment  is  hysterectomy.  The  prognosis  is  fairly  good. 
Of  17  cases,  8  had  no  recurrence  (Gessner). 

Endothelioma  of  the  corpus  uteri  is  the  rarest  of  all  uterine 
growths.  A  io.^  only  are  recorded.  ^  The  clinical  features  indicate 
a  malignant  growth  of  the  carcinomatous  type  originating  in  the 
endothelium  of  the  lymph-spaces.  The  treatment  is  hysterectomy. 
The  condition  has  more  pathological  than  clinical  interest.  From 
the  latter  point  of  view  it  must  be  regarded  as  a  cancer. 

'Grafe.  "Ein  Fall  von  Endothelsarcom  des  Uterus,"  Diss.,  Greifswald,  1897. 
Pick,  "Arch.  f.  Gyn.,"  Bd.  xlix,  p.  i. 


Menstruation  373 

Myxomatous  polyps  of  the  corporeal  endometrium  are  of  fre- 
quent occurrence.  They  are  an  accompaniment  and  a  local 
exaggeration  of  hyperplastic  glandular  endometritis.  The  symp- 
toms are  the  same  as  in  the  latter  disease  except  that  the  metror- 
rhagia is  exaggerated.  The  same  treatment  is  indicated,  but  it 
must  be  remembered  that  the  curet  may  slip  over  the  growth 
and  the  result  of  the  treatment  be  a  failure.  It  should  there- 
fore be  an  invariable  rule  of  practice  to  follow  every  curettage 
for  metrorrhagia  by  an  exploration  of  the  uterine  cavity  with  a 
forceps,  such  as  the  Emmet  curetment  forceps.  Metroscopy,  or 
the  inspection  of  the  uterine  cavity  through  an  endoscope,  has 
not  yet  proved  a  success.  Digital  exploration  of  the  uterine 
cavit)^  is  often  inconvenient  or  impracticable,  and  is  not  so  certain 
as  the  skilful  use  of  the  forceps.  Time  and  again  the  author 
has  removed  with  the  latter  mucous  polyps  and  fragments  of 
chorion  that  curets  of  different  sizes  and  shapes  (Sims'  and 
Martin's)  had  passed  over  in  repeated  scrapings  of  the  endo- 
metrium. 

Mucous  polyps  of  the  endometrium  may  undergo  telangiec- 
tatic, cystic,  mucous,  carcinomatous,  and  sarcomatous  degenera- 
tion. They  should  always  be  subjected  to  microscopical  exami- 
nation after  removal. 

Menstruation. — Menstruation  is  the  periodic  discharge  of  a 
sanguineous  fluid  from  the  mucosa  of  the  uterus  and  perhaps 
from  that  of  the  Fallopian  tubes,  ^  occurring  during  the  time  of  a 
woman's  sexual  activity,  from  puberty  until  the  menopause. 
Since  the  earliest  ages  of  medical  literature  many  theories  have 
been  advanced  to  account  for  menstruation.  The  oldest  expla- 
nation, entertained  until  comparatively  recent  times,  was  founded 
upon  woman's  supposed  uncleanliness.  Menstruation  was 
thought  to  be  an  effort  on  the  part  of  nature  to  rid  the  woman's 
body  of  noxious  humors. ^  Later,  it  was  explained  that  woman 
was  plethoric  and  that  nature  provided  a  periodic  vent  for  her 
superfluous  blood.  In  modern  times  Pfliiger  has  advanced  the 
theory  that  menstruation  occurs  in  consequence  of  a  congestion 
brought  about  as  follows  :  A  Graafian  follicle  by  its  growth 
finally  produces  so  great  a  reflex  irritation  as  to  determine  a  local 
congestion,  which  manifests  itself  in  a  bloody  discharge  from  the 

^  There  is  always  some  mucous  secretion  from  the  tubes  during  menstruation,  but 
it  is  not  always  bloody. 

2  Many  popular  superstitions  are  founded  upon  this  idea ;  for  example,  that  a 
drop  of  menstrual  blood  withers  a  flower,  and  that  a  menstruating  woman  in  a  dairy 
turns  the  milk  sour.  The  modern  .physician  is  still  influenced  by  this  old  supersti- 
tion, if  the  author  may  judge  from  grave  discussions  he  has  heard  as  to  the  propriety 
of  allowing  a  menstruating  nurse  to  be  present  during  the  performance  of  an  abdom- 
inal section. 


374  Menstruation 

uterine  mucous  membrane.  Sigismund,  Lowenhardt,  and  Reichert 
propounded  the  doctrine  that  menstruation  occurs  because  the 
ovum  discharged  prior  to  the  menstrual  period  is  not  impregnated; 
consequently,  failing  this  stimulus  to  further  growth  and  develop- 
ment, a  retrograde  change  with  bleeding  occurs  in  the  uterine 
mucous  membrane.  If  one  accepts  this  theory,  it  is  not  the 
ovum  from  the  last  period,  but  that  discharged  at  the  time  of  the 
first  absent  period,  which  is  impregnated.  As  a  matter  of  fact, 
the  cause  of  menstruation  is  one  of  the  many  life-phenomena  at 
present  beyond  human  comprehension.  All  that  can  be  said  is 
that  a*  nervous  influence  proceeds  periodically  from  the  sympa- 
thetic ganglia  in  the  lower  abdomen  and  pelvis,  stimulating  and 
congesting  the  sexual  organs.  We  can  no  more  account  for  this 
nervous  action  than  we  can  explain  the  nervous  force  which 
continues  respiration  from  the  moment  of  birth  until  death. 
Certain  facts  from  comparative  physiology,  however,  throw  a 
glimmer  of  light  upon  the  subject.  For  instance,  it  is  asserted 
that  if  sheep  fall  into  heat  and  are  not  gratified,  the  rut  returns 
in  a  month.  Menstruation  in  the  female  is  obviously  what  rut  is 
in  the  lower  animals,  and  the  bloody  discharges  from  human 
females  are  probably  the  result  of  their  erect  posture  and  the 
pelvic  congestion  which  is  a  consequence  of  it. 

The  mechanism  of  menstruation  is  better  understood  than  its 
causes.  It  is  mainly  a  diapedesis  of  blood  through  delicate, 
newly  formed  capillaries  in  a  thickened  and  congested  endome- 
trium, the  provision  for  carrying  blood  to  the  membrane  being 
better  than  that  for  bearing  it  away  by  the  efferent  vessels.  Some 
of  the  newly  formed  delicate-w^alled  capillaries  no  doubt  rupture. 
Leopold  has  given  the  following  description  of  the  uterine 
mucous  membrane  during  menstruation  :  The  mucous  mem- 
brane is  8  millimeters  (0.3 15  inch)  thick,  swollen,  dark  brownish- 
red,  soft  almost  to  liquefaction,  but  perfectly  intact  and  separated 
by  a  sharply  defined  boundary-line  from  the  paler  muscular 
tissue  of  the  uterus.  The  uterine  glands,  0.5  to  0.75  millimeter 
(0.0197  to  0.0296  inch)  wide,  are  considerably  lengthened  and 
can  be  seen  by  the  naked  eye.  In  the  superficial  portion  of  the 
mucous  membrane,  which  is  very  well  preserved  and  only  in 
certain  spots  lacks  its  epithelium  and  subjacent  cells,  may  be  seen 
an  immense  and  enormously  hypertrophied  capillary  network,  the 
vessels  of  which  have  irregular  outlines  and  lie  in  the  uppermost 
layer  of  the  mucous  membrane. 

Gebhard  ^  gives  the  following  results  of  his  studies  :  There 
are  three  stages:  (i)  Premenstrual  congestion,  in  which  the  capil- 
laries are  distended ;  there  is  a  transudation  or  exudation  of  blood 

'Veit's  "Handbuch  der  Gyn.,"  vol.  iii. 


Time  of  First  Occurrence  and  Cessation        375 

into  the  intercellular  tissue,  the  meshes  of  which  are  widened, 
and  an  accumulation  of  blood  under  the  surface  epithelium,  which 
is  raised  into  little  hillocks  by  the  subepithelial  hematomata.  (2) 
Escape  of  the  accumulated  blood  through  the  interstices  between 
the  epithelial  cells  which  are  pushed  apart  and  some  of  which 
may  be  carried  away  by  the  blood  as  it  forces  its  way  out.  There 
is  also  some  desquamation  of  the  glandular  epithelium.  (3)  Post- 
menstrual  involution.  The  mucosa  shrinks.  The  extravasated 
blood  remaining  in  the  intercellular  tissue  is  absorbed.  The  sur- 
face epithelium  lifted  away  from  its  subjacent  attachments  by  the 
interstitial  hemorrhage  sinks  again  to  its  normal  level  and  adheres 
again  to  subjacent  structures. 


^ 

-— X 

'  v'  ■' ' 

>i'^''"'\ 

.•^ 

■~s 

^7-'.- 

'•'" 

V'  --:  v'- 

-  ^"'"X/ 

^■■^  ?_  , 

■•. 

;:{-^s'Jf-^' 

'   _-- 

■•;-•'•:■ 

y'l.  i^>-.' 

J'-'.-}';'''  ■/ 

-.'■;     / 

^ 

-<rs-.-- ', "'".  ■»%  ;  '<.■:  .'•     . 

-...?' 

tr-  :.  -'     ■' .  • 

1% 

V- 

4 

^'-;^^Se 

1     ; 

'■fw.'J 

"■^^dX 

''w/j^' 

:--^.u.irr.. 

!^'- 

••■'V-.'-'"' 

:.r~i(; 

^^5' 

f:'> 

/ 

W^:- 

"•'.">'  '-■'■" 

:  ~\\ 

f 

}(■■ 

A-.  -■ 

%i^'iS^-'':A 

i  ■' 

■'  ;.?;'■■ 

•  :"'''■.    y-o. 

H' 

,  f  • 

',-1  :■■■    <-  1      .  y, 

•*'  '.''.'■ 

t 

■--'  ^'-  .'< 

-V 

i<'^U 

^'/f"^ 

^-■'  :54-''t 

■  •'( 

-J'  •'';.•, 

--'  js:^  ■ 

';;r4 

=^  ■:  * ' 

r/. 

m:Mh 

Lr' 

i"  y'Y 

y" .'  '■ 

.f/J'-*y 

:.'    ;.'■   'y~ 

■f  i 

f  •'■-. 

^,^ 

■m-^. 

'i 

''• . '  ■' . 

^ 

Fig.   362. — Postmenstrual  regeneration  of  uterine  mucous  membrane  (Gebhard). 


From  these  observations  of  Leopold  and  Gebhard,  and  from 
other  studies  of  mucous  membrane  removed  by  the  curet  during 
menstruation  and  observed  in  recently  extirpated  uteri,  it  appears 
that  the  theory  of  hemorrhage  in  consequence  of  degeneration  of 
the  mucous  membrane  is  untenable. 

The  uterus  is  increased  in  size  and  softened  in  consistency, 
these  changes  being  most  marked  just  before  the  flow  appears. 
The  uterine  cavity  is  enlarged,  the  cervix  is  slightly  dilated,  and  the 
cervical  glands  secrete  an  increased  amount  of  mucus.  The  tubes 
and  ovaries  are  swollen,  heavy,  and  congested.  There  are  certain 
clinical  phenomena  of  menstruation  which  must  often  be  taken 
into  account  by  the  physician. 

Time  of  First  Occurrence  and  Cessation. — The    onset  of  men- 


^^^  Menstruation 

struation  is  influenced  by  race,  climate,  mode  of  life,  heredity, 
and  genital  sense.  In  temperate  climates  and  in  the  home  of  the 
Teutonic  and  Anglo-Saxon  races,  menstruation  occurs  oftener  in 
the  fifteenth  than  in  any  other  year.  In  these  same  races  trans- 
planted to  the  eastern  middle  seaboard  of  the  United  States,  men- 
struation appears  a  year  or  two  earlier. 

In  Hungary,  the  three  races,  Slav^onic,  Magyar,  and  Jewish, 
living  side  by  side  in  the  same  climate,  begin  to  menstruate,  respec- 
tively, at  sixteen,  fifteen,  and  thirteen  years  of  age.  Hindu  girls 
of  Calcutta  and  negresses  of  Jamaica,  living  in  similar  climatic 
conditions,  begin  to  menstruate  at  the  eleventh  and  at  the  fifteenth 
year.  Climate,  however,  may  influence  the  onset  of  menstruation. 
Puberty  is  seen  earliest  in  hot,  latest  in  cold  climates.  It  appears 
at  eighteen  }'ears  in  the  girls  of  Lapland  and  at  ten  years  in  Egypt 
and  Sierra  Leone. ^  Altitude  is  also  a  factor  to  be  considered. 
Menstruation  appears  earlier  in  the  lowlands  than  in  the  high- 
lands. 

The  social  conditions  of  a  girl  determine,  to  a  certain  extent, 
the  age  at  which  menstruation  begins.  If  she  lives  in  a  city, 
subjected,  perhaps,  to  indiscriminate  association  with  the  other 
sex  and  to  sexual  temptations,  the  function  appears  earlier  than 
it  does  in  the  country,  or  in  a  girl  carefully  brought  up  in  com- 
parative seclusion.  The  same  rule  applies  to  lower  animals.  If 
a  bull  is  admitted  to  the  pasture  of  a  herd  of  heifers,  heat  appears 
earlier  in  the  latter  than  it  would  if  they  were  segregated.  The 
girls  of  the  leisure  or  wealthy  classes  begin  to  menstruate  much 
earlier  than  those  of  the  working  classes. 

It  is  a  matter  of  common  observation  that  peculiarities  of 
menstruation  run  in  certain  families.  Thus,  through  several  gen- 
erations of  females  menstruation  appears  late  and  ends  early,  or 
vice  versa.  By  genital  sense  is  meant  the  strength  of  sexual 
feeling.  In  women  of  strong  sexual  passion  the  function  of 
menstruation  is  commonly  instituted  earlier  and  lasts  to  a  greater 
age  than  common.  Precocious  menstruation  is  not  uncommonly 
associated  with  nymphomania. 

Menstrual  Molimina. — By  this  term  is  meant  the  local  and  reflex 
subjective  symptoms  of  menstruation.  There  is  a  feeling  of 
weight  and  heaviness  in  the  pelvic  organs,  due  to  their  conges- 
tion and  increased  size.  There  is  a  general  nervous  excitation, 
so  that  women  disposed  to  hysteria  and  epilepsy  exhibit  out- 
breaks at  this  and  perhaps  at  no  other  time.  The  uterus  under- 
goes rhythmical  contractions  which  may  be  painful.    The  breasts 

1  Engelmann  shows  that  this  is  by  no  means  an  invariable  rule.  In  some  of  the 
most  northerly  of  Esquimau  tribes  puberty  appears  as  early  as  in  the  tropics  ("Ameri- 
can Gynecology,"  March,  1903). 


The  Character  of  the  Flow 


zn 


swell  and  may  secrete  milk.  There  may  be  intense  pain  in  the 
mammary  glands  before  the  menstrual  flow  appears.  There  is  a 
disposition  to  salivation,  which  may  be  pathologically  exagger- 
ated. The  thyroid  gland  is  enlarged,  and  the  tonsils,  epiglottis, 
and  vocal  cords  are  swollen,  so  that  singers  may  have  a  tone 
less  clear  and  true  than  at  other  times.  The  turbinated  bones 
and  the  mucous  membrane  of  the  nasal  septum  swell.  There  is 
increased  vascular  tension,  increased  activity  of  the  heart,  shown 
by  sphygmographic  tracings,  and  the  pulse  is  accelerated.  The 
temperature  is  elevated  by  0.5°  C.  The  skin  is  more  vascular 
and  shows  unusual  pigmentation,  especially  in  the  dark  rings 
under  the  eyes.  There  is  increased  sweat  and  an  increase  of  the 
secretion  of  the  sebaceous  glands,  especially  those  of  the  exter- 


Fig.  363. — Line  A  B  indicates  the  variations  in  the  physiological  processes  in 
menstruating  women  ;  the  abscissa  line  c  d  indicates  the  days  of  the  month  ;  ;«  n,  the 
menstrual  period;  the  ordinate  line  ce  indicates  the  activity  of  the  physiological 
processes  (v.  Ott). 


nal  genitals.  Desquamation  of  the  lingual  epithelium  and 
ptyalism  have  been  noted  ;  also  a  secretion  of  intestinal  mucus 
with  diarrhea.  In  some  women  herpes  is  a  constant  accompa- 
niment of  menstruation,  v.  Ott  has  demonstrated  a  regularly 
recurring  wave  in  all  the  physiological  processes  of  women, 
shown  by  heat  production,  muscular  strength,  lung  capacity, 
force  of  inspiration  and  expiration,  and  tendon  reflexes.  The 
greatest  activity  is  manifested  just  before  the  appearance  of  the 
flow,  when  there  is  a  sudden  subsidence. 

The  Character  of  the  Flow. — The  discharge  consists,  in  great 
part,  of  blood  which  is  more  watery  than  ordinary  venous  blood. 
It  is  mixed  vdth  cervical  mucus  and  is  alkaline  in  reaction.  It 
contains,  besides  the  blood  and  its  corpuscles,  mucous  secretion 


378  Menstruation 

from  the  glands  along  the  genital  canal,  and  squamous  and  col- 
umnar epithelial  cells,  detritus,  and  micro-organisms  of  various 
sorts.  It  is  dark  in  color,  and  should  not  clot.  It  has  a  peculiar 
odor  from  the  secretions  of  the  sebaceous  glands  at  the  vaginal 
•outlet,  excited,  as  are  all  the  structures  of  the  genital  canal, 
to  unusual  activity. 

The  Duration  of  the  Flow. — Menstruation  rarely  lasts  less  than 
three  days  ;  the  average  duration  is  four  or  five  days  ;  a  continu- 
ance of  seven  days,  if  the  natural  and  invariable  habit  of  the  in- 
dividual, may  indicate  nothing  pathological.  In  the  first  two  or 
three  days  the  greatest  amount  of  blood  is  lost.  After  that  the 
discharge  grows  less  until  it  ceases.  A  leukorrhea  or  mucous 
discharge  for  a  day  or  two  preceding  and  after  the  cessation  of 
the  bloody  flow  is  common. 

The  Interval  between  the  Menstrual  Discharges. — In  70  per 
cent,  of  women  there  is  an  interval  of  twenty-eight  days  from 
the  first  day  of  a  menstruation  to  the  first  day  of  the  next.  The 
interval  is  thirty  days  in  13.7  per  cent.,  twenty-one  days  in  1.6 
per  cent.,  twenty-seven  days  in  1.4  per  cent.  (Krieger). 

The  Quantity  of  the  Flow. — The  actual  quantity  of  discharge 
during  menstruation  has  been  estimated  at  four  to  six  ounces.  It 
is  not  practicable  for  the  physician,  however,  accurately  to  meas- 
ure the  amount  of  flow.  He  must  estimate  it  by  the  number  of 
napkins  worn  in  twenty-four  hours.  If  a  woman  is  obliged  to 
change  her  napkins  during  the  height  of  the  flow  more  than  three 
times  a  day,  or  to  wear  them  double,  the  quantity  of  the  flow  is 
•excessive. 

The  Cessation  of  the  Flow. — The  menstrual  flow  ceases  usu- 
ally in  the  forty-fifth  year,  becoming  infrequent  and  scanty 
over  a  period  of  six,  nine,  or  twelve  months,  until  it  stops  alto- 
gether. There  are  exceptions,  however,  to  this  rule.  A  woman 
who  begins  to  menstruate  much  later  than  the  fifteenth  year  will 
•often  have  the  menopause  before  forty.  Or,  if  she  begins  to 
menstruate  early,  she  may  continue  beyond  the  forty-fifth  year. 
A  menorrhagia  may  precede  the  menopause.  An  unusually  free 
discharge  may  be  the  last  that  the  patient  experiences.  There  is 
a  sudden  cessation  of  menstruation. 

As  a  rule  it  may  be  stated  that  a  woman  menstruates  from 
about  her  fourteenth  to  her  forty-fifth  year.  Precocious  men- 
struation, however,  has  been  recorded  in  the  infant  of  one  to  two 
years  old,  and  the  discharge  has  continued  to  the  sixty-fifth  and 
even  to  the  eightieth  year.  The  menopause  exceptionally  occurs 
from  the  twenty-ninth  to  the  thirty-fifth  year.  It  is  seen  earlier 
in  hot  than  in  temperate  climates. 

The  clinical  phenomena  of  the  menopause   are  mainly  due 


Ovulation   and   Menstruation  379 

to  vasomotor  disturbances ;  the  flashes  of  heat,  tendenc}^  to 
sweats,  palpitation  of  the  heart,  headaches,  neurasthenia,  and 
hysteria,  are  the  chief  symptoms.  The  atrophic  changes  in  the 
genital  organs  are  marked.  The  uterus  shrinks,  the  muscular 
tissue  disappears,  the  uterine  cavity  is  shortened  or  even 
obliterated,  the  mucosa  is  thin,  the  epithelial  elements  atrophy, 
the  glands  are  reduced  in  number.  The  vaginal  portion  of 
the  cervix  is  small,  and  no  longer  projects  from  the  vaginal 
vaults  ;  the  vagina  is  shortened,  narrowed,  and  its  walls  lose  their 
elasticity.  The  fat  disappears  from  the  vulva,  the  labia  majora 
are  flabb)',  the  labia  minora  shrink,  the  mons  veneris  loses  its 
prominence,  the  pubic  hairs  turn  gray;  the  ovaries  shrink  and 
become  cirrhotic  ;  the  blood-vessels  undergo  hyaline  degeneration, 
and  the  Graafian  follicles  disappear. 

The  Connection  between  Ovulation  and  Menstruation.— Neither 
one  of  these  functions  is  dependent  upon  the  other,  but  they  both 
depend  upon  a  common  cause — the  periodic  nervous  excitation 
and  congestion  due  to  an  impulse  from  the  sympathetic  nervous 
system.  Dependent  as  they  are  upon  the  same  cause,  their  oc- 
currence is  usualh'  synchronous  ;  that  is,  the  ovule  is  discharged 
at  the  height  of  menstrual  congestion.  But  this  is  by  no  means 
the  invariable  rule.  Leopold/  in  an  examination  of  twenty-nine 
pairs  of  ovaries  removed  on  successive  days  up  to  the  thirty-fifth 
after  a  menstrual  period,  found  a  Graafian  follicle  bursting  on  the 
eighth,  twelfth,  fifteenth,  sixteenth,  eighteenth,  twentieth,  and 
thirty-fifth  days  after  the  menstrual  period.  In  other  words, 
ovulation  may  occur  without  menstruation  at  any  time  in  the  in- 
termenstrual interval.  In  five  cases  there  was  no  ovulation  at  the 
menstrual  period,  or  menstruation  occurred  without  ovulation. 
Many  examples  might  be  given,  from  clinical  observation,  of  the 
mutual  independence  of  these  two  functions.  The  common  oc- 
currence of  impregnation  during  lactation  is  a  good  instance  of 
ovulation  without  menstruation.  ^  Menstruation  after  oophorec- 
tomy and  during  the  first  three  months  of  pregnancy  occurs 
without  ovulation.  I  attended  in  her  first  childbirth  a  young 
woman  twent}'-two  years  old  who  had  never  menstruated.  She 
had  obviously,  however,  ovulated.  In  the  child-marriages  of 
India  impregnation  has  been  known  to  precede  menstruation. 
Renondin  saw  pregnancy  and  labor  in  a  woman  sixty-one  years 

1  "  x-Xrch.   f.  Gyn.,"  Bd.  xxix,  S.  347. 

2  Remfry  ("  Revue  Internationale  de  Medecine  et  de  la  Chirurgie,"  1896,  No.  5) 
has  found  by  an  investigation  among  900  nursing  women  that  in  57  pcr  cent,  only  did 
there  occur  an  absolute  amenorrhea.  Menstruation  was  regular  in  20  per  cent,  and 
irregular  in  43  per  cent.  It  was  also  common  for  conception  to  occur  during  lacta- 
tion, 60  per  cent,  of  the  menstruating  women  conceiving.  Among  the  non-menstruat- 
ing women  but  6  per  cent,  conceived  during  lactation. 


380  Menstruation 

old,  who  had  ceased  to  menstruate  twelve  years  before.  Re- 
peated ovulation  without  menstruation  is  seen  also  in  those  curi- 
ous cases  of  postmarital  amenorrhea,  lasting  for  years.  The 
wife  of  a  physician  among  my  acquaintances  menstruated  once 
after  marriage  ;  in  the  following  fifteen  years  she  bore  ten  chil- 
dren without  ever  menstruating.  Three  years  after  the  birth  of 
the  last  child,  or  eighteen  }-ears  since  its  cessation,  menstruation 
returned  copiously  and  regularly,  but  more  frequently  than  nor- 
mal, for  twelve  years.  The  menopause  then  began,  at  the  age 
of  forty-eight.^  A  recent  ovulation  has  been  observed  in  an 
extra-uterine  pregnancy  of  three  months'  duration  (Slavyansky). 
Coitus  four  days  postpartum  has  resulted  in  impregnation 
(Kr6nig). 

It  is  necessary  occasionally  to  remove  the  ovaries  in  cases 
of  ill-developed,  infantile  wombs,  associated  with  well-developed 
ovaries  in  which  there  is  a  violent  exaggeration  of  the  menstrual 
molimina  every  month  without  a  discharge  of  blood  and  the  con- 
sequent relief  of  menstrual  congestion.  The  ovaries  are  found, 
after  their  removal,  to  be  filled  with  well-developed  Graafian  folli- 
cles and  numerous  depressions  representing  corpora  lutea.  In 
these  ovaries  there  may  be  a  corpus  luteum  that  would  answer 
for  an  illustration  of  the  yellow  body  of  pregnancy.  It  may  also 
be  necessary  to  remove  the  ovaries  that  have  been  left  behind  in 
a  hysterectomy.  The  menstrual  molimina  due  to  ovulation  with- 
out menstruation  may  be  so  severe  as  to  cause  unendurable 
symptoms  with  perhaps  hysterical  convulsions. 

Apparently  the  cessation  of  ovulation  determines  the  cessa- 
tion of  menstruation.  The  vast  majority  of  women  who  have 
been  subjected  to  a  complete  oophorectomy  cease  to  men- 
struate, and  therefore  it  appears  that  the  ovaries  dominate  the 
function  of  menstruation  ;  but  an  explanation  may  be  found  in 
the  destruction  of  the  sympathetic  nerves  running  in  the  broad 
ligament  to  the  uterus.  A  case  is  recorded  of  the  cessation  of 
menstruation  upon  the  rupture  of  an  intraligamentary  pregnancy 
with  disintegration  of  the  broad  ligament,  though  the  ovary  was 
unaffected.  ' 

The  Medical  Management  of  Puberty,  Menstruation,  and  the  Meno- 
pause.— A  physician's  advice  is  not  often  sought  unless  there  is 
something  pathological  in  these  phenomena.  Nevertheless,  a 
word  of  warning  may  often  be  of  service  about  the  guarded  in- 
formation a  mother  should  give  her  daughter  so  that  she  shall 
not  be  frightened  by  the  first  appearance  of  the  menstrual  bleeding 
and  about  the  prudence  that  should  be  observed  during  menstrua- 

'  Similar  cases  are  reported  in  "  Amer.  Jour,  of  Obstet.,"  1892,  p.  352,  and 
"  N.  Y.  Med.  Record,"  1893,  P-  7^7- 


Amenorrhea  381 

tion.  The  disastrous  effects  of  dancing,  bathing,  catching  cold, 
strenuous  mental  or  physical  effort  during  the  periods,  and  the 
possible  life-long  invalidism  that  may  result  should  be  pointed 
out.  The  disturbances  of  the  menopause  often  demand  the 
physician's  attention.  They  are  productive  of  so  much  discom- 
fort, are  so  often  exaggerated  beyond  physiological  limits,  and 
may  last  so  long  that  the  patient  is  impelled  to  seek  relief. 

Freedom  from  care,  relaxation  of  physical  and  mental  effort, 
regular  periods  of  complete  rest  once  or  twice  a  day,  a  re- 
duction of  the  diet,  and  regulation  of  the  bowels  should  be  the 
first  principles  of  treatment.  Bromids^  and  other  nerve  sedatives 
should  be  administered  sparingly  and  reserved  for  aggravated 
exacerbations  of  the  nervous  disturbances.  The  exhibition  of 
ovarian  extract  from  time  to  time  in  decreasing  doses  seems  logical. 
It  is  difficult  to  judge  of  its  efficacy,  as  the  natural  tendency  is 
toward  improvement,  which  may  or  may  not  be  hastened  by  the 
remedy. 

Amenorrhea,  or  the  absence  of  menstruation,  is  physiological 
before  puberty,  after  the  menopause,  during  pregnancy  and  lacta- 
tion.     At  other  times  it  is  pathological. 

The  causes  are  numerous  :  There  may  a  periodic  discharge 
of  blood  from  the  uterine  and  tubal  mucosa,  but  it  may  not  escape 
externally  owing  to  an  atresia  of  the  genital  canal.  The  uterus 
may  be  arrested  in  development,  atrophied  or  superinvoluted,  so 
that  there  may  be  menstrual  molimina  and  ovulation,  but  no  dis- 
charge of  blood.  The  uterine  cavity  may  be  obliterated  by 
adhesive  inflammation  after  a  curettage  or  labor.  There  may 
be  ill  development  or  absence  of  the  internal  genitalia,  in  which 
case  there  is  neither  menstruation  nor  molimina.  If  the  ovaries 
are  ill  developed  or  destroyed  as  egg-producing  organs  by  dis- 
ease, menstruation  ceases.  Amenorrhea  is  not  infrequently  noted 
with  ovarian  cysts  and  fibroid  tumors,  especially  if  the  latter  are 
subperitoneal.  Amenorrhea  may  be  noted  in  normal  sexual 
organs  as  the  result  of  psychical  disturbances  :  dread  of  ille- 
gitimate impregnation  ;  neurasthenia  and  hysteria ;  strenuous 
mental  effort,  as  in  the  ambitious  school-girl  ;  ardent  desire 
for  maternity  or  a  belief  that  conception  has  occurred ;  and 
sudden  fright.  Change  of  climate  is  a  common  cause  of 
amenorrhea.  A  large  proportion  of  the  Irish  girls  who  emi- 
grate to  America  miss  their  sickness  for  months  until  they 
are  acclimated.  A  change  of  residence  from  the  country  to  the 
city  sometimes  has  the  same  effect,  and  so  has  a  change  of  oc- 
cupation, especially  from  an   open-air  life  to  a  sedentary  indoor 

^  Sodii  bromid.,  gr.  x,  and  ^ij  of  elixir  of  the  valerianate  of  ammonium  is  a  use- 
ful routine  prescription. 


382  Abnormalities  of  Menstruation 

existence.  Catching  cold  during  menstruation,  sea-bathing,  cold- 
water  baths  or  douches,  and  wet  feet  often  suddenly  check  the 
flow  {supprcsio  niensiuni),  and  subsequent  periods  for  some  time 
afterward  may  pass  without  a  discharge. 

Many  diseases  of  the  general  system  or  of  organs  and  structures 
remote  from  or  unconnected  with  the  sexual  apparatus  are  associ- 
ated with  amenorrhea.  Hypertrophic  rhinitis  has  been  known 
to  bear  a  causal  relation  to  it.  Obesity,  especially  if  rapidly  de- 
veloped toward  middle  age,  is  often  a  cause. 

Chlorosis  is  the  commonest  cause  among  the  constitutional 
diseases.  If  it  does  not  produce  an  actual  amenorrhea  in  young 
girls,  the  discharge  is  thin,  watery,  and  scanty.  Acute  and 
chronic  anemia,  leukemia,  impaired  nutrition,  convalescence  from 
the  acute  infectious  fevers,  such  as  typhoid  and  scarlet  fever, 
chronic  nephritis  and  diabetes,  myxedema,  akromegaly,  Addison's 
disease,  may  all  determine  a  cessation  of  menstruation. 

The  association  of  tuberculosis  and  amenorrhea  is  recognized 
by  the  laity.  There  is  a  widespread  belief  that  cessation  of 
menstruation  is  the  precursor  of  a  decline,  cause  and  effect  being 
transposed  in  the  popular  mind.  As  a  matter  of  fact,  the 
primary  stages  of  phthisis  are  usually  associated  with  menor- 
rhagia.      The  amenorrhea  is  a  later  manifestation. 

Drunkenness,  opium  and  other  drug  habits,  and  saturnism 
may  check  the  menstrual  discharge. 

Finally,  amenorrhea  may  develop  in  a  perfectly  healthy  young 
woman  without  ascertainable  cause  and  may  continue  for  months 
and  years  without  other  symptoms  than  the  anxiety  that  her  pe- 
culiarity excites  in  herself  and  her  nearest  relatives. 

The  symptoms  of  amenorrhea  may  be  nothing  but  the  absence 
of  the  discharge.  In  gynatresia  the  uterine  cramps  and  molim- 
ina  increase  in  severity  with  each  period.  In  chlorosis,  the 
scanty  periodic  mucous  discharge  may  be  accompanied  with 
much  local  pain  and  is  usually  associated  with  obstinate  con- 
stipation. The  most  serious  general  symptoms  of  amenorrhea 
are  the  psychical :  hysteria,  melancholia,  and  even  a  species  of 
dementia  have  been  noted,  disappearing  on  the  reappearance  of 
menstruation.  Severe  diseases  and  functional  disturbances  of  the 
eye  are  recorded  with  amenorrhea,  only  amenable  to  treatment 
after  the  re-establishment  of  the  function. 

JTJie  treatment  of  ametiorrhea  should  obviously  be  directed  to 
the  cause  and  must  vary  greatly  in  individual  cases.  Gynatresia 
indicates  the  removal  of  the  obstacle  to  the  escape  of  the  dis- 
charge. Grave  defects  of  development,  destructive  diseases  of 
the  genitalia  are  incurable.  Psychical  causes  demand  appro- 
priate  treatment ;    the   rest   cure  is    indicated   for   hysteria    and 


Amenorrhea  383 

neurasthenia.  The  woman  who  fears  impregnation  or  beHeves 
it  has  occurred  begins  to  menstruate  if  her  fears  are  allayed  or 
she  is  convinced  of  her  error. 

The  overworked  school-girl  should  be  taken  from  school  to 
a  healthy  life  in  the  open  air.^  The  amenorrhea  from  change  of 
climatelor  occupation  disappears  when  the  individual  is  accus- 
tomed TO  her  new  environment.  The  cessation  of  menstruation 
from  exposure  to  cold  is  usually  cured  in  time,  if  further  im- 
prudence is  avoided.  Constitutional  diseases,  if  curable,  should 
be  treated  without  reference  to  the  menstrual  function,  which 
will  be  restored  as  the  general  health  is  improved.  Chloro.sis 
requires  good  hygiene,  the  persistent  use  of  blood  tonics,  the 
improvement  of  the  digestion,  and  the  correction  of  the  consti- 
pation. Pyrophosphate  of  iron  (gr.  v)  dissolved  in  malt  extract 
is  a  good  routine  prescription.  Blaud's  pills,  pepto-mangan,  bone- 
marrow,  and  other  modern  remedies  for  the  improvement  of  the 
constitution  of  the  blood,  such  as  the  peptonates  and  albuminates 
of  iron,  may  be  alternated  with  the  pyrophosphate.  If  no  cause 
can  be  discovered  for  the  amenorrhea ;  if  the  general  health  is 
good  ;  if  there  are  no  local  or  general  symptoms,  and  if  the  ab- 
sence of  menstruation  excites  no  alarm  or  anxiety  in  the  patient, 
treatment  is  uncalled  for. 

Nothing  is  more  illogical  than  the  common  practice  of  con- 
tinually prescribing  an  emmenagogue  or  resorting  to  local  treat- 
ment for  the  cure  of  amenorrhea.  Medicinal  emmenagogues, 
however,  and  electricity  or  irritating  applications  to  the  endo- 
metrium may  be  required,  if  systemic  treatment  and  hygienic 
management  fail,  or  if  the  cause  of  the  amenorrhea  is  an  ill- 
developed  uterus  or  one  in  the  early  stages  of  atrophy  or  sub- 
involution. 

The  best  medicinal  emmenagogues  are  oxalic  acid,  gr.  y^,  in 
syrup  of  lemon  and  water,  ad  f  Sss,  four  times  a  day  ;  the  sali- 
cylates ;  permanganate  of  potassium,  gr.  i— ij,  t.  i.  d.  ;  aloes,  pearls 
of  apiolin,  and  binoxid  of  manganese  (gr.  ij).  De wees'  famous 
emmenagogue  mixture  is  : 

Tinct.  ferri  chlorid 6  parts. 

Tinct.  cantharides 2     " 

Tinct.  aloes 8     " 

Ammoniated  guaiac 24     " 

Simple  syrup 58     " 

The- irritation  of  the  endometrium  by  the  introduction  of  the 

^The  ideal  school  for  girls  or  college  for  young  women  should  be  conducted 
with  an  eye  to  the  individual  scholar.  Her  studies  should  be  lightened  at  her 
periods.  The  Podsnapian  plan  of  ignoring  the  function  of  menstruation  as  an  indel- 
icate subject  is  too  often  responsible  for  the  acquisition  of  a  more  or  less  super- 
ficial mental  culture  at  the  expense  of  chronic  invalidism  and  a  diminished  capacity 
for  maternity. 


384  Abnormalities  of  Menstruation 

sound  and  the  application  of  iodin  has  brought  on  menstruation. 
The  best  local  application  is  indisputably  the  electrical  current — 
either  galvanism  i  5-40  milliamperes,  the  negative  pole  being  in- 
serted in  the  uterus,  or  the  faradic  current  by  a  bipolar  electrode 
in  liter o.  The  latter  is  best  adapted  to  cases  of  ill-developed, 
atrophic,  and  subinvoluted  uteri  ;  it  should  be  applied  systemati- 
cally and  regularly  over  a  considerable  space  of  time.  The  former 
is  indicated  before  the  time  of  the  expected  period.  Measures  to 
induce  a  congestion  of  the  pelvis  are  sometimes  effectual.  Warm 
foot-  and  sitz-baths  and  horse-back  riding  are  the  best. 

Vicarious  menstruation  is  the  periodic  discharge  of  blood  from 
some  other  mucous  surface  than  that  of  the  uterine  cavity. 

The  nasal  mucous  membrane  is  the  commonest  source  of 
vicarious  menstruation.  ^  It  may  occur  at  any  age  :  Cases  are 
reported  of  precocious  monthly  discharges  in  infancy  ;  of  men- 
struation beginning  as  a  periodic  epistaxis  for  a  few  months  until 
the  uterine  discharge  was  established  ;  of  a  regular  monthly  dis- 
charge from  the  nose  from  the  thirteenth  to  the  forty-first  year. 
Vicarious  menstruation  may  cease  when  the  woman  becomes 
pregnant  and  recur  after  the  convalescence,  just  as  a  normal  men- 
struation should  do.  The  next  most  common  source  of  vicarious 
menstruation  is  the  lungs.  The  trachea,  larynx,  stomach,  the 
ear,  the  eyes,  and  the  thyroid  gland  (through  a  fistula)  are  other 
sources.  Hancock^  has  reported  a  case  of  bleeding  from  the 
left  breast  preceding  each  period.  In  the  author's  service  in  the 
Howard  Hospital  a  neurasthenic  young  woman  had  vicarious 
menstruation  from  the  rectum,  with  severe  molimina. 

The  treatment  of  vicarious  menstruation  is  to  establish  a  flow 
from  the   uterus  by  the  measures   recommended  for  amenorrhea. 

Menorrhagia  is  an  increased  or  prolonged  menstrual  dis- 
charge. It  has  many  causes  ;  hyperplastic  endometritis  is  the 
commonest.  Other  local  diseases  manifested  by  periodic  hemor- 
rhages are:  chronic  metritis;  sclerosis  of  the  uterine  blood-vessels; 
tertiary  syphilis  ;  polyps  and  fibroid  tumors  ;  malignant  disease 
and  tuberculosis  ;  inflammation  and  neoplasms  of  the  tubes  and 
ovaries.  Constitutional  diseases  causing  menorrhagia  are  anemia 
and  chlorosis  in  exceptional  cases,  though  amenorrhea  is  usually 
a  result  of  these  diseases  ;  hemorrhagic  diathesis,  gout,  scurvy, 
the  acute  infectious  fevers,  malaria,  influenza,  and  saturnism. 
The  early  stages  of  phthisis  are  commonly  associated  with 
menorrhagia.      Cirrhosis  of  the  liver,  heart  disease,  and  nephritis 

^  The  author  has  seen  a  case  of  pelvic  peritonitis  with  intestinal  adhesions  fol- 
lowed by  tympany,  amenorrhea,  and  the  subjective  signs  of  pregnancy  for  nine 
months.      There  was  a  regular  monthly  discharge  of  blood  from  the  nose. 

2  "  Med.  News,"  1895. 


Dysmenorrhea  385 

are  also  causes.  Intestinal  parasites  have  been  noted  as  a  cause. 
The  menorrhagia  often  becomes  a  metrorrhagia — that  is,  a  con- 
tinuous bleeding  from  the  womb  or  hemorrhages  at  odd  times 
without  distinct  periodicity. 

The  treatment  may  be  medicinal  (ergotin,  hydrastinin,  stypti- 
cin,  suprarenal  extract),  but  should  usually  be  a  curettage  and  a 
careful  exploration  of  the  uterine  cavity  to  detect  a  polyp  or  other 
neoplasm.  The  positive  pole  of  a  galvanic  current  (15—40  milli- 
amperes)  is  one  of  the  best  hemostatic  agents  for  the  endome- 
trium. Intra-uterine  applications  of  iodin  or  of  nitrate  of  silver 
solution  are  at  times  effective,  but  they  have  disadvantages, 
already  pointed  out.  Since  1898  cauterization  of  the  endo- 
metrium by  steam  has  had  an  extensive  vogue  in  Germany. 
Free  steam  is  injected  in  the  uterine  cavity  {atnwkausis)  or  the 
steam  circulates  through  metal  tubing  without  coming  in  actual 
contact  with  the  endometrium  [zestokmisis).  The  cauterization  is 
difficult  to  regulate,  is  not  entirely  safe,  predisposes  to  cervical 
stenosis  or  atresia,  and  may  obliterate  the  uterine  cavity.  There 
seems  to  be  little  to  recommend  this  treatment  in  preference  to 
other  methods  more  easily  controlled,  safer,  and  quite  as  effi- 
cacious. It  might  be  employed  after  everything  else  had  failed 
and  before  resort  to  a  hysterectomy,  which  has  rarely  been  re- 
quired in  uncontrollable  bleeding  near  the  menopause.  ^ 

A  permanent  cure  of  menorrhagia  or  metrorrhagia  can  not 
be  expected  unless  the  cause  is  removed,  if  possible,  and  a  treat- 
ment of  the  cause  alone  is  sometimes  sufficient  to  cure  the  menor- 
rhagia. Thus,  the  treatment  of  a  chronic  malaria  has  checked 
excessive  menstruation,  without  any  local  measures  whatever, 
and  the  removal  of  intestinal  parasites  has  had  the  same  result. 
In  obstructed  circulation  from  weak  heart,  valvular  disease,  and 
cirrhosis  of  the  liver,  digitalis  or  strophanthus  must  be  added  to 
the  treatment  or  may  be  all  that  is  required. 

Dysmenorrhea.— Painful  menstruation  in  which  the  suffering 
exceeds  the  usual  depression,  discomfort  in  the  pehis  and  back, 
and  the  nervous  excitation  commonly  experienced  by  all  women 
is  one  of  the  commonest  gynecological  affections  demanding  the 
physician's  attention.  Unfortunately  its  cure  is  as  puzzling  a 
problem  as  confronts  the  clinician. 

At  one  time  dysmenorrhea  was  regarded  as  indicating  simply 
a  mechanical  difficulty  in  the  escape  of  the  menstrual  blood,  and 
this  impression  prevails  largely  to-day.  Painful  menstruation, 
however,  is  by  no  means  such  an  uncomplicated  subject.     It  may 

1  The  apparatus  for  injecting  steam  into  the  uterus  is  made  by  Hahn  u.  Lochel, 
Dantzig.      See   '' Encyklopadie   der  Geb.    u.   Gyn.,"  Leipzig,  1900  ;  also,    "  Atmo- 
kausis  and  Zestokausis,"  Pincus,  Wiesbaden,  1903. 
25 


386  Abnormalities  of  Menstruation 

depend  upon  a  hyperesthesia  of  the  endometrium.  When  the 
mucosa  is  infiltrated  with  blood  and  the  surface  epithelium  is  ele- 
vated by  extravasation,  acute  suffering  is  produced,  aggravated 
by  painful  contractions  of  the  myometrium  and  reflex  nervous  dis- 
turbances. It  may  depend  upon  an  ill  development  of  the  uterine 
blood-vessels  which  are  of  insufficient  caliber  to  contain  the  excess 
of  blood,  upon  lack  of  development  in  the  uterus  itself,  and  a  de- 
ficient capacity  of  the  uterine  ca\■it^^  It  may  be  mechanical,  espe- 
cially if  a  narrow  cervical  canal  is  still  further  obstructed  by  angu- 
lation in  an  acute  anteflexion,  or  if  the  cervical  canal  is  obstructed 
by  a  polyp.  It  may  be  due  to  disturbances  in  the  general  ner- 
vous system  without  any  local  disorder  at  all ;  and,  finally,  it  may 
depend  upon  ovarian  or  tubal  disease.  The  prolonged  recur- 
rence of  uterine  irritation  in  cases  of  dysmenorrhea  commonly 
causes  an  endometritis  by  which  the  symptoms  are  aggravated. 
Hence,  it  is  frequently  stated  that  the  suffering  increases  as  the 
girl  grows  older  and  that  the  discharge  has  become  more  pro- 
fuse. The  usual  position  of  the  uterus  in  cases  of  dysmenorrhea 
is  one  of  exaggerated  anteflexion,  Avhich  is  an  evidence  of  ill 
development  and  may  be  a  cause  of  mechanical  difficulty.  Some 
of  the  most  aggravated  cases,  however,  are  seen  with  retrover- 
sion in  unmarried  girls,  on  account,  perhaps,  of  the  endome- 
tritis and  pelvic  congestion  which  are  results  of  the  displace- 
ment. 

It  can  readily  be  understood  why  marriage  and  maternity  so 
often  cure  dysmenorrhea.  Coitus  and  pregnancy  stimulate  the 
development  of  the  uterus.  Labor  removes  any  mechanical 
obstacle  to  the  escape  of  the  discharge.  The  exfoliation  of  the 
decidua  and  the  evolution  of  a  new  endometrium  in  the  puer- 
perium  may  replace  a  hyperesthetic  with  a  normal  mucosa. 

The  symptoms  of  dysmenorrhea  are  pains  of  a  cramp-like 
nature  with  exacerbations  and  remissions  in  the  uterine  region, 
continuing  during  the  first  twelve  to  thirty-six  hours  of  the  flow, 
associated  often  with  nausea  and  vomiting  and  with  nervous  dis- 
turbances, reaching  in  the  worst  cases  to  the  grade  of  hyster- 
ical convulsions  or  causing  syncope.  The  suffering  may  not  be 
localized  in  the  pelvic  region  at  all,  but  may  be  manifested  in  a 
severe   headache  or  entirely  in  psychical  outbreaks. 

In  the  intermenstrual  intervals  there  is  no  discomfort,  except 
in  some  cases  a  manifestation  of  intermenstrual  pain  or  "Mittel- 
schmerz."  Usually  the  pain  is  more  severe  the  greater  the  quan- 
tity of  the  discharge.  It  is  not  uncommon,  however,  in  cases 
of  ill-developed  uteri,  to  obtain  a  history  of  severest  pain  with  a 
scanty  discharge,  relieved  or  mitigated  if  the  flow  becomes  nor- 
mal in  quantity.      If  the  dysmenorrhea  depends  upon  ovarian  or 


Dysmenorrhea  387 

tubal  disease,  the  pain  is  greatest  before  and  after  the  flow,  being 
reheved  during  the  time  of  the  actual  discharge  and  is  localized 
above  one  or  both  groins. 

In  cases  of  hyperesthetic  endometrium  the  introduction  of  a 
uterine  sound  and  the  impact  of  its  point  upon  the  fundal  endo- 
metrium often  elicit  the  same  kind  of  pain  which  the  patient  expe- 
riences during  menstruation. 

The  suffering  of  dysmenorrhea  is  influenced  greatly  by  the 
patient's  health  and  the  condition  of  the  nervous  system.  The 
overworked  school-girl  removed  from  her  studies  and  leading  a 
healthy  open-air  life  may  be  entirely  relieved  without  other  treat- 
ment. 

Many  young  women  who  suffer  severely  every  month  in  the 
tr}^ing  climate  and  the  feverish  social  life  of  American  cities  are 
entirely  free  from  pain  in  their  summer  outings  or  during  a  trip 
abroad. 

Treatment. — There  was  a  time  when  every  case  of  dysmen- 
orrhea was  supposed  to  indicate  a  forcible  dilatation  of  the  cer- 
vix and  a  curettage.  While  it  is  undeniable  that  these  measures 
are  often  of  the  greatest  service  and  should  frequently  be  the 
starting-point  of  treatment,  the  physician  who  depends  upon 
them  alone  in  every  case  will  subject  himself  and  his  patients 
to  many  a  disappointment. 

The  neurasthenic  woman  requires  appropriate  treatment  for 
her  nervous  condition  and  may  need  nothing  else.  The  young 
woman  under  a  nervous  strain  in  her  occupation  or  social  life 
with  a  hyperesthetic  endometrium  may  be  cured  by  a  better 
regulated  existence,  freedom  from  care  or  excitement,  and  mod- 
erate outdoor  exercise.  Ill-developed  uteri  with  scanty  menstru- 
ation may  require  the  treatment  of  chlorosis  with  abdominal  mas- 
sage and  Swedish  movements. 

A  stimulant  treatment  of  the  myometrium  and  of  the  endo- 
metrium by  the  negative  pole  of  a  galvanic  current  (15—40  mil- 
liamperes)  and  by  faradism  is  often  of  undoubted  advantage  in 
such  cases,  but  there  are  grave  objections  to  local  treatment  in 
young  unmarried  women. 

Such  an  abnormality  as  retroversion  should  be  corrected,  best 
by  the  operative  treatment  in  unmarried  women,  preceded  by  a 
dilatation  and  curettage. 

A  laxative  just  before  the  expected  period  and  rest  in  bed 
for  the  first  twelve  or  twenty-four  hours  of  the  flow  should  be 
recommended  in  all  cases  until  the  course  of  treatment  to  effect 
a  permanent  cure  has  been  decided  upon  and  carried  out. 

The  medicinal  relief  of  the  intense  suffering  of  dysmenorrhea 
is  a  problem  frequently  and  urgently  presented  to  the  physician. 


T^8S  Abnormalities  of  Menstruation 

but  is  one  often  most  difficult  of  solution.  A  hypodermic  of 
morphia  reliev^es  the  pain  most  quickly  and  effectually,  but  there 
is  great  danger  by  its  use  every  month  of  establishing  the  opium 
habit.  Antipyrin,  phenacetin,  and  acetanilid  are  often  of  service. 
Acetanilid  (gr.  ij)  with  carbonate  of  ammonia  (gr.  iij)  every  hour 
for  three  doses  is  as  effectual  as  any  single  remedy  except  mor- 
phia. Apiol  is  usually  disappointing.  Bromid  of  sodium  (gr.  v) 
and  elixir  of  valerianate  of  ammonium  (f  5ij)  every  four  hours  are 
of  service,  combined  with  the  acetanilid  and  carbonate  of  am- 
monium. Fluid  extract  of  viburnum  prunifolium  (foj),  diluted, 
every  three  hours,  may  prove  a  useful  adjuvant  of  other  treat- 
ment. The  Germans  recommend  scarification  of  the  cervix  and 
local  bloodletting  just  before  the  period,  but  frequently  repeated 
local  treatments  are  not  to  be  recommended  in  young  women. 

The  tubal  or  ovarian  forms  of  dysmenorrhea  can  as  a  rule 
only  be  cured  by  operative  treatment. 

Membranous  dysmenorrhea  or  exfoliative  endometritis  is  charac- 
terized by  the  expulsion  of  a  fibrinous  cast  of  the  uterine  cavity 
or  of  the  superficial  portion  of  the  mucosa  at  the  menstrual 
period,  accompanied  usually,  but  not  always,  with  severe  pain. 
There  is  no  fever,  but  often  a  pronounced  malaise  for  some  days 
after  the  flow.  During  this  time  there  is  frequently  a  profuse 
leukorrhea.  The  discharge  of  membrane  may  occur  regularly 
with  every  period  or  only  at  intervals  of  three  or  four  months. 
The  discharged  membrane  may  be  a  complete  sac,  like  the 
decidua  in  some  cases  of  extra- uterine  pregnancy,  but  it  is  more 
likely  to  be  expelled  in  several  pieces.  It  may  be  i  to  3  milli- 
meters thick.  The  microscopical  examination  always  shows  an 
interstitial  endometritis,  with  a  development  of  the  interglandular 
cells  to  a  degree  that  suggests  the  decidual  cells  of  pregnancy, 
but  there  is  not  the  same  increase  in  the  amount  of  protoplasm 
nor  the  universal  presence  of  these  cells  that  is  characteristic  of 
the  mucosa  of  gestation.  The  superficial  epithelium  is  preserved 
in  places  or  is  wanting  entirely.  The  glands,  few  in  number, 
run  an  irregular  course.  The  tissue  does  not  stain  well  and 
suggests  some  degree  of  maceration,  which  has  no  doubt  oc- 
curred in  the  time  intervening  between  its  detachment  and  expul- 
sion from  the  uterus  (Gebhard).  The  microscopical  changes 
found  in  the  discharged  membrane  may  not  be  discoverable  in 
the  mucous  membrane  removed  by  the  curet  in  the  intermenstrual 
intervals.  The  inflammatory  process,  therefore,  recurs  at  each 
period  and  subsides  in  the  interval.^ 

'  Kollmann  ("  Miinch.  ined.  Wochensclir. ,"  1901,  No.  37)  denies  that  there  is 
a  uniform  histology  of  memVjianous  dysmenorrhea,  the  membrane  in  his  investiga- 
tions being  sometimes  normal, sometimes  showing  interstitial  or  glandular  hypertrophy, 
round-cell  infiltration,  or  fibrinous  exudate. 


Sterility  389 

P^ndometritis,  heredity,  imprudence  during  the  periods,  have 
been  described  as  the  causes  of  membranous  dysmenorrhea. 
The  majorit)'  of  the  cases  are  inexpHcable.  In  twenty-seven 
cases  Lohleini  found  21  of  the  women  sterile,  6  who  had  borne 
children. 

Treatment  is  often  of  no  avail.  Curettage  and  cauterization 
of  the  uterine  cavity  with  pure  carbolic  acid  may  prove  effectual ; 
so  may  electric  cauterization  of  the  endometrium.  Improve- 
ment of  the  general  health,  open-air  exercise,  change  of  air  and 
scene  may  be  required. 

Sterility. — If  a  woman  remains  unimpregnated  eighteen 
months  after  marriage,  without  taking  measures  to  prevent  con- 
ception, she  may  be  called  sterile.  In  about  20  per  cent,  of 
sterile  marriages  the  fault  Hes  with  the  male.  His  spermatozoa 
should  be  examined  under  the  microscope  and  his  potentia  coetuidi 
should  be  ascertained  in  every  case  as  part  of  the  routine  investiga- 
tion of  the  cause  of  sterility  in  the  female.  The  causes  of  ster- 
ility in  the  wife  may  be  classified  as  follows  : 

Anatomical  or  developmental  defects  preventing  normal  in- 
semination or  presenting  mechanical  obstacles  to  the  access  of 
the  spermatozoa  to  the  ovum.  Absence  or  stenosis  of  the  genital 
tract  in  whole  or  in  part,  absence  of  the  cervical  canal  and  uterine 
cavity,  lack  of  patency  in  the  tubes,  absence  or  arrested  develop- 
ment of  the  ovaries,  are  a  necessary  bar  to  impregnation.  So  is 
an  imperforate  hymen  or  atresia  of  any  portion  of  the  genital 
canal.  The  commonest  developmental  anomaly  responsible 
for  sterility  is  stenosis  of  the  cervical  canal  and  a  U-shaped  ante- 
flexion of  the  uterus. 

Diseases,  injuries,  and  displacements  of  the  vulva,  such  as 
vaginismus,  kraurosis,  and  neoplasms  may  prevent  normal  insemi- 
nation, and  are  usually,  but  not  necessarily,  a  bar  to  conception, 
the  mere  deposition  of  semen  upon  the  external  genitals  being 
followed  sometimes  by  impregnation.  An  injury  of  the  vulva 
which  the  author  has  twice  seen  responsible  for  sterility  is  a  per- 
foration of  the  fossa  navicularis  into  the  rectum  at  the  first  coitus, 
the  hymen  remaining  intact.  Subsequent  intercourse  occurred 
by  way  of  the  fistula. 

Acquired  atresia  of  the  vulva  and  vagina  may  prevent  im- 
pregnation. In  a  case  of  the  author's,  the  vagina  was  reduced  by 
acquired  atresia  to  a  narrow  sinus  throughout  its  whole  length, 
barely  admitting  a  surgeon's  probe.  Impregnation  occurred  by 
the  deposition  of  semen  upon  the  vulva.  Coitus  in  such  cases 
has  not  infrequently  been  practised  by  the  urethra,  which  has 
been  gradually  dilated.      With  a  coincident  vesicovaginal  fistula 

1  "Centralbl.  f.  Gyn.,"  1886,  p.  465. 


390  Sterility 

above  the  site  of  complete  atresia  impregnation  is  possible  and 
has  occurred.  Injury  of  the  pelvic  floor,  destruction  of  the  peri- 
neum, inversion  of  the  vagina,  may  be  causes  of  sterihty  by  pre- 
\enting  the  retention  of  seminal  fluid. 

Retroversion  of  the  uterus  may  be,  but  is  by  no  means  neces- 
sarily, a  cause  of  sterility.  In  the  supine  position  the  cervix  is 
tilted  upward  and  is  not  bathed  as  it  should  be  in  the  seminal 
lake  occupying  the  posterior  vault  of  the  vagina.  The  motility 
of  the  spermatozoa  may  overcome  the  obstacle,  but  cases  of  steril- 
ity are  cured  sometimes  by  a  pessary  or  the  operative  treatment 
of  retroversion. 

A  complete  prolapse  of  the  uterus  usually  prevents  concep- 
tion, but  in  a  case  of  the  author's  impregnation  took  place  in  spite 
of  a  total  prolapse  of  years'  duration.  A  fibromyoma  or  other 
neoplasm  of  the  uterus  or  of  the  endometrium  may  prevent  con- 
ception by  opposing  obstacles  to  the  ascent  of  the  spermatozoa, 
but  the  motility  of  the  latter  may  enable  them  to  surmount  bar- 
riers mountains  high  in  comparison  with  their  microscopical  size 
and  to  traverse  the  most  tortuous  canal. 

The  commonest  disease  of  the  genitalia  accountable  for  steril- 
ity is  salpingitis  with  closure  of  the  abdominal  ostium  by  adhe- 
sive inflammation.  The  common  cases  of  "one-child  sterility" 
are  usually  due  to  this  cause,  and  it  also  explains  the  infrequency 
of  conception  in  prostitutes.  Diseases  and  neoplasms  of  the 
ovaries  destroying  them  as  egg-producing  glands,  their  inclosure 
in  an  adventitia  of  inflammatory  exudate,  and  a  thickening  of 
the  proper  capsule  prevent  ovulation  and  therefore  preclude 
conception. 

Anemia  and  wasting  diseases  may  deprive  the  Graafian  folli- 
cles of  the  blood  required  for  their  maturation  and  rupture  and  so 
may  prevent  ovulation. 

The  Psychic  Causes  of  Sterility. — It  is  true  that  women  may 
be  impregnated  while  asleep,  drunk,  asphyxiated,  or  unconscious 
from  any  cause ;  by  the  mere  deposition  of  semen  upon  the  exter- 
nal genitalia;  by  the  artificial  injection  of  seminal  fluid  into  the 
genitalia;  without  ever  experiencing  the  least  sexual  sensation. 
Nevertheless,  a  lack  of  aflfinity  between  the  man  and  woman,  an 
absence  of  sexual  passion,  and  of  an  orgasm,  may  account  for 
sterility. 

Treatment. — It  is  obvious  that  the  treatment  must  be  directed 
to  the  cause  and  must  vary  greatly  in  individual  cases.  A  care- 
ful study  of  the  patient  should  naturally  precede  the  treatment. 
The  case  may  call  for  the  removal  of  tumors  from  the  vulva,  tlie 
cure,  if  possible,  of  kraurosis,  the  gradual  dilatation  of  the  introi- 
tus  vagince,  or  cutting  the  levator  ani  muscles  in  vaginismus ;  the 


Treatment  391 

correction  of  atresia  or  stenosis  in  the  genital  canal ;  the  excision 
of  the  hymen  and  the  closure  of  fistulae;  the  repair  of  vaginal 
injuries,  or  the  reposition  of  a  displaced  uterus.  A  tonic  treat- 
ment for  anemia  may  be  indicated.  Most  frequently  a  forcible 
dilatation  of  the  cervical  canal  and  a  curettage  of  the  uterus  are 
required.  If  there  is  evidence  in  physical  signs  or  subjective 
symptoms  of  tubal  disease,  a  trap-door  excision  of  the  tubal 
walls  or  a  partial  exsection  of  the  tube  may  permit  impregnation. 
The  release  of  the  ovaries  from  a  bed  of  exudate  or  false 
membrane  may  have  the  same  result.  In  cases  demanding  total 
salpingectomy,  pregnancy  has  followed  the  implantation  of  the 
ovary  in  the  uterine  cornu.  Experiments  upon  the  lower  ani- 
mals, as  well  as  upon  human  beings,  have  demonstrated  the 
feasibility  of  transplanting  the  ovary  to  some  other  situation  than 


Fig.  364. — Excision  of  tubal  wall  for  sterility  from  occlusion  of  the  abdominal  orifice. 

its  normal  one  in  the  peritoneal  cavity,  or  even  of  implanting  the 
ovary  recently  removed  from  another  person  with  continued 
functional  activity  and  a  subsequent  conception. 

A  myomectomy  or  the  removal  of  any  pelvic  or  abdominal 
tumor  exerting  pressure  upon  the  genital  canal  may  remove 
the  obstacle  to  conception.  From  their  nature  many  cases  are 
incurable.  Occasionally  a  marriage  sterile  for  many  years  may 
inexplicably  prove  fruitful  without  special  treatment.  The  author 
has  had  under  his  charge  in  confinement  a  woman  who  conceived 
for  the  first  time  after  more  than  twenty  years  of  married  life, 
when  she  had  given  up  all  hope  of  such  an  event.  The  physi- 
cian should  usually  be  careful  not  to  inform  his  patient  bluntly 
that  she  is  hopelessly  sterile.  She  should  be  allowed  to  enter- 
tain some  hope  of  maternity  until  the  lapse  of  years  has  recon- 
ciled her  to  the  idea  that  she  can  not  expect  offspring. 


PART  VIII. 

THE  FALLOPIAN  TUBES;  EXTRA-UTERINE  PREG- 
NANCY. 

THE  FALLOPIAN  TUBES. 

The  uterine  or  Fallopian  tubes  run  from  the  cornua  of  the 
uterus,  in  the  upper  edges  of  the  broad  ligament,  to  the  ovaries. 
They  are  divided  into  the  following  parts  :  The  uterine  ostium, 
a  funnel-shaped  opening  into  the  uterine  cavity ;  the  intramural 
or  uterine  portion  running  through  the  uterine  wall;  the  isthmus, 
the  narrow  inner  third  of  the  free  tube,  springing  from  the  uterus 
between  the  insertions  of  the  round  and  ovarian  ligaments,  but 
at  a  shghtly  higher  level ;  the  ampulla,  the  expanded  outer  two- 
thirds  of  the  tube ;  the  infundibulum,  a  funnel-shaped  expansion 
at  the  end  of  the  tube  in  the  bottom  of  which  is  the  abdominal 
ostium  and  the  fimbriae,  surrounding  the  infundibulum,  one  of 
which,  the  ovarian  fimbria,  runs  to  the  upper  or  tubal  pole  of  the 
ovary,  to  which  it  is  attached.  There  is  a  distinct  groove  along 
the  upper  surface  of  this  fimbria,  hned  with  epithelium.  The 
other  fimbria  are  usually  in  contact  with  the  ovary.  The  upper 
edge  of  the  broad  ligament  to  which  the  tube  is  attached  or  in 
which  it  is  embedded  is  called  the  mesosalpinx. 

The  Fallopian  tube  has  the  following  average  dimensions  : 

Length  12.5  cm. 

Width  of  the  isthmus  near  the  uterus ■  0.3    " 

Greatest  width  of  the  ampulla 0.8    " 

Length  of  the  isthmus 4-5    " 

"       "     "    fimbriae 1.25  " 

"       "     "    ampulla  .    .         8.0    " 

"       "     "    ovarian  fimbria 2.75  " 

The  tubal  walls  consist  of  a  mucous,  a  muscular,  and  a  serous 
coat.  The  tubal  mucosa  possesses  no  glands  and  no  submucosa. 
It  has  the  round  cells  found  in  the  interglandular  substance  of 
the  uterine  mucosa.  It  is  thrown  into  longitudinal  folds  or  plica- 
tions, beginning  in  the  isthmus  as  slight  elevations,  but  be- 
coming so  well  marked  in  the  ampulla  that  the  folds  reach  across 
the  lumen  of  the  tube,  giving  such  a  complicated  appearance 
to  a  transverse  section  that  this  portion  of  the  tubal  canal  is 
called  the  labyrinth.  The  epithelium  is  ciliated,  the  cilia  lashing 
toward  the  uterus.  The  fimbriae  are  clothed  on  their  inner  sur- 
face with  this  ciliated  epithelium,  and  the  groove  of  the  ovarian 
fimbria  is  similarly  provided,  the  epithelium  growing  beyond  the 

392 


Anatomy  •  393 

upper  edges  of  the  groove,  encroaching  somewhat  upon  the  serosa 
of  the  mesosalpinx,  and  being  continuous  with  the  columnar 
epithelium  covering  the  ovary. 

The  muscular  coat  has  three  layers  :  an  inner,  feebh'  de- 
veloped, of  longitudinal  fibers  ;  a  middle,  well  developed,  of  circu- 
lar fibers  ;  and  an  outer  thin  layer  of  longitudinal  fibers. 

The  serous  coat  has  likewise  three  layers  :  a  subserosa,  a 
tunica  adventitia,  and  a  tunica  serosa. 

The  blood-vessels  are  a  terminal  branch  of  the  uterine  artery, 
given  off  just  in  front  of  the  ovarian  ligament  and  running  along 
the  under  surface  of  the  tube  to  anastomose  with  a  branch  of  the 


Fig.   365. — Normal   Fallopian  tube,  uterine  end:    w,  Mucosa;   /,   lumen  of  canal ; 
t,  tube-wall  (McConnell  and  J.  C.  Hirst). 

ovarian  artery.  Veins  accompany  the  arteries.  The  tubal  walls 
themselves  are  richly  supplied  with  blood-vessels.  There  is  a 
well-developed  venous  plexus  under  the  serous  coat. 

The  lympliatics  of  the  tubes  are  two  or  three  branches  run- 
ning along  the  upper  margin  of  the  broad  ligaments,  anastomos- 
ing with  ducts  from  the  uterus,  with  the  plexus  at  the  hilus  of  the 
ovary  and  running  to  the  lumbar  glands. 

The  nerves  are  derived  from  the  uterovaginal  plexus  and  from 
that  of  the  ovarian  artery.  Branches  accompany  the  blood-vessels 
and  form  a  plexus  in  the  subserosa,  from  which  terminal  filaments 
go  to  the  other  coats  of  the  tube. 


394 


The  Fallopian  Tubes 


Dependent  usually  from  the  ovarian  fimbria  is  a  small  cystic 
body,  the  hydatid  of  Morgagni,  with  a  long,  slender  pedicle.  Its 
wall  is  connective  tissue,  its  lining  membrane  a  pavement  epithe- 
lium, sometimes  columnar  or  ciliated,  and  its  contents  a  clear 
fluid.  It  varies  in  size  from  that  of  a  pea  to  that  of  a  hickory 
nut.  Its  pedicle  may  reach  a  length  of  3  centimeters  or  more. 
It  represents  the  terminal  end  of  the  Miillerian  ducts. 

Diseases  of  the  Tubes. — The  tubes  may  be  congested;  they 
may  be  displaced.  They  are  subject  to  a  variety  of  inflamma- 
tions ;  and  they  may  be  the  seat  of  neoplasms. 

Congestion  of  the  tubes  may  be  the  result  of  obstructed  circu- 


Fig.   366. — Normal  Fallopian  tube,  section  near  abdominal  end  :  t.  Tubal  wall  ;  v, 
villus-like  plications  (McConnell  and  J.  C.  Hirst). 


lation,  of  a  systemic  infection,  such  as  cholera,  of  external  burns, 
or  of  phosphorus-poisoning.  The  circulation  is  obstructed  by 
torsion,  by  displacements  of  the  tubes,  as  in  inguinal  hernia,  and 
inversion  of  the  uterus,  by  constricting  bands  of  adhesive  lymph, 
by  thrombosis  of  the  spermatic  vein,  by  a  passive  congestion 
of  all  the  pelvic  organs,  or  by  heart  and  liver  diseases. 

Torsion  of  the  tubes  may  be  so  extreme  as  to  sever  the  tube 
at  its  inner  third  with  the  corresponding  portion  of  the  broad  and 
ovarian  ligaments.  In  the  case  diagrammatically  represented  in 
figure  387  the  outer  two-thirds  of  the  tube  with  the  ovary  were 
torn  loose  and  lifted  out  of  the  abdomen  by  light  traction  ;  there 
was  no  hemorrhage  ;  the  ovary  and  tube  were  necrotic.      A  case 


Inflammations  of  the  Tubes  395 

is  reported  of  detachment  of  the  tube  and  its  reattachment  in  the 
lumbar  region,  where  it  was  nourished  by  a  vessel  from  the  aorta. 

The  congested  tube  is  swollen,  dark  red  in  color,  and  the 
fimbriae  may  appear  actually  erected.  There  may  be  extrav- 
asations of  blood  in  the  walls,  hemorrhages  into  the  lumen, 
hyaline  degeneration  of  the  blood-vessels,  necrosis  of  the  mucosa 
and  of  the  muscularis. 

Displacements  of  the  tubes  accompany  displacements  of  the 
uterus ;  in  retroflexion  they  are  necessarily  carried  downward  and 
backward  ;  in  prolapse  they  may  accompany  the  descent  of  the 
uterus;  in  inversion  they  lie,  partly  at  least,  in  the  cup  formed  by 
the  inverted  uterus.  They  are  sometimes  enormously  elongated 
by  intraligamentary  cysts,  over  the  top  of  which  they  run,  reach- 
ing a  length  of  30  centimeters  or  more.^  They  have  been  found 
in  inguinal  and  crural  hernias.  They  may  run  an  oblique  course 
upward  and  forward  to  the  iliac  fossae,  or  they  may  be  arrested 
by  adhesions  in  embryonal  life  at  the  level  of  the  kidneys  by  an . 
attachment  of  the  ovary  in  that  situation  and  the  prevention  of  its 
normal  descent.'-^ 

Inflammations  of  the  tubes  are  non-infectious  and  infectious. 
The  former  may  be  due  to  cold,  injuries,  the  reflux  of  irritating 
substances  injected  into  the  uterus,  such  as  iodin,  and  to  the  ex- 
anthemata. The  acute  congestion  of  menstruation  may  be  ex- 
aggerated to  the  degree  of  inflammation  and  stagnation  of  the 
tubal  secretion  in  consequence  of  an  abnormal  tortuosity  of  the 
tube  may  prove  a  chronic  irritant  exciting  inflammation. 

The  infectious  inflammations,  due  to  the  presence  of  bacteria, 
are  much  commoner  than  the  non-infectious.  Infection  of  the 
tubes  can  occur  from  the  peritoneum,  the  intestines,  the  uterus, 
the  blood-  and  lymph-channels.  Tuberculosis  is  a  good  example 
of  infection  of  the  tube  from  the  peritoneum.  The  bacteria  of 
the  bowel  gain  access  from  adhesions  between  a  coil  of  intestine 
and  the  tube,  or  secondarily  from  the  peritoneal  cavity.  Gono- 
cocci  most  commonly  advance  along  the  uterine  mucosa,  through 
the  uterine  ostium  to  the  tubal  mucosa  ;  so  do  colon  bacilli 
and  staphylococci.  Streptococci  usually  penetrate  the  myo- 
metrium and  make  their  way  to  the  tubes  by  way  of  the 
lymphatics  or  blood-channels.  Anaerobic  saprophytes  are  present 
in  cases  of  hematosalpinx  complicating  acquired  gynatresia  or  in 
any  case  of  retention  of  putrescible  material  in  the  tubes. 

The  commonest  infecting  micro-organism  in  the  tube  is  the 
gonococcus.     In  218  pus-tubes  they  were  found  74  times  (Klein- 

^  Payer  reports  a  tube  76  centimeters  long  ("  Monatsschr.  f.  Geburtsh.  u. 
Gyn.,"  Bd.  xiv,  p.  745). 

-  Busse,  "Monatsschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  xiii,  H.  6. 


396  The  Fallopian  Tubes 

bans).  Streptococci  are  next  in  frequency;  tubercle  bacilli 
next ;  then  follow  colon  bacilli,  staphylococci,  diplococci  pneu- 
moniae, and  pneumobacilli.  It  is  usually  impossible  to  demon- 
strate the  infecting  agent  in  a  pyogenic  inflammation  of  the 
tubes.  In  370  pus-tubes  examined  by  Wertheim,  Witte,  Martin, 
and  Menge,  227  were  sterile.  The  micro-organisms  expire 
b\'  being  confined  in  a  narrow  space,  destroyed  by  their  own 
secretions  and  by  the  compression  to  which  the  tubal  con- 
tents are  subjected.  The  kind  of  infection  can  only  be  in- 
ferred from  the  patient's  history  and  physical  signs  elsewhere, 
which  may  point  to  gonorrhea  or  to  a  puerperal  infection,  proba- 


Fig.   367. — Acute  septic  salpingitis,  showing  the  round-cell  infiltration:  e.  Exudate; 
/,  tube-wall ;  v,  villi,  infiltrated  with  round  cells  (McConnell  and  J.  C.  Hirst). 

bly  streptococcic.  An  auto-infection  of  the  tubes  is  described, 
but  the  infectious  bacteria  must  at  some  time  have  come  from 
without,  usually  along  the  genital  canal  from  gonorrheal  infection 
in  coitus  or  otherwise,  from  puerperal  infection,  from  the  introduc- 
tion of  instruments  into  the  uterus,  or  from  operations  upon  the 
genitalia;  or  possibly  from  the  other  sources  of  tubal  infection 
enumerated,  the  peritoneum,  the  bowel,  or  the  lymph-  and  blood- 
chaimels. 

Pathological  Anatomy. — The  mucosa  of  the  tubes  exhibits 
round-cell  infiltration,  hyperplasia  of  the  mucous  folds,  agglu- 
tination of  the  apposed  surfaces  at  the  terminal  expansion  of  the 


Inflammations  of  the  Tubes 


397 


Fig.  368. — Pyosalpinx:  /,  Tube-wall ;-',  pseudoglandular  or   follicular  arrangement, 
due  to  adhesions  of  plications  (McConnell  and  J.  C.  Hirst). 


Fig.  369. — Pus-tube. 


Fig.  370. — Pus-tube. 


Fig-   371- — Pus-tube. 
398 


Inflammations  of  the  Tubes 


399 


plications,  and  the  inclosure  of  cyst  spaces  beneath  {salpingitis 
pseudofollicidaris  cystica).  The  cihated  epithelium  is  long  pre- 
served in  these  deeper  spaces,  while  it  may  early  disappear,  being 
replaced  by  granulation  tissue  on  the  periphery  of  the  plications. 
There  may  be  such  an  intimate  union  of  the  latter  by  adhesions 


Fig.   372. — Pus-tube. 


Fig.   373. — Pus-tube,  laid  open  by  median  longitudinal  section. 


that  there  is  no  longer  a  continuous  tubal  canal.  The  usual 
effect  of  any  microbic  infection  of  the  tubal  mucosa  is  pus-pro- 
duction. This  is  most  commonly  the  case  in  gonorrheal  infec- 
tion, but  not  invariably.  The  less  virulent  micro-organisms,  such 
as  staphylococci  and  colon  bacilli  and  any  of  the  others,  if  they 


400 


The  Fallopian  Tubes 


Fig.    374- — Tubo  ovarian  cyst. 


Fig.    375. — Interstitial  salpingitis. 


Inflammations  of  the  Tubes 


401 


are  in  a  condition  of  diminished  virulence,  produce  a  tubal  catarrh, 
with  a  thin  mucoserous  secretion. 

An  early  result  of  infectious  endosalpingitis  is  the  closure  of 
the  abdominal  ostium  of  the  tube.  The  thickened  tubal  walls, 
congested  or  inflamed  in   sympathy  with   the   inflammation  of 


Fig.    376. — Interstitial  salpingitis ;   tube  laid  open  by  median  longitudinal  section. 


Fig.   377. — Interstitial  salpingitis. 

the  interior,  grow  out  beyond  the  fimbriae,  encircling  them,  so  that 
they  adhere  by  their  external  peritoneal  surfaces  and  in  time  com- 
pletely disappear.  Another  method  of  closure  is  by  an  exudate  of 
lymph  around  and  over  the  fimbriae,  sealing  the  infundibulum.  In 
this  form  of  peritoneal  inflammation  around  the  fimbriated  ex- 
26 


402  The  Fallopian  Tubes 

tremity  of  the  tubes  the  ovary  is  often  involved,  so  that  one  or 
more  folUcles  open  when  they  rupture  into  an  inclosed  space 
containing  the  tubal  fimbriae.  The  fluid  continuing  to  accumulate 
and  the  follicle  to  expand,  a  follicular  cyst  of  the  ovary  by 
gradual  distention  grows  around  the  abdominal  end  of  the  tube  ; 
hence  in  a  tubo-ovarian  cyst,  as  it  is  called,  the  fimbriae  are  always 
found  in  the  interior  of  the  ovarian  follicular  space,  usually 
adherent  to  its  wall. 

As  pus  accumulates  within  the  tube  in  a  pyosalpinx,  the 
lumen  is  distended  and  the  mucosa  is  enormously  hypertro- 
phied.    The  degree  of  distention  depends  to  a  great  extent  upon 


Fig.    378. — Showing  thickening  of  tubal   wall  in  chronic  interstitial  salpingitis:    /, 
Lumen  of  tube ;  f.c,  peritoneal  coat;  i.w,  tube-wall  (McConnell  and  J.  C.  Hirst). 

the  implication  of  the  tubal  walls  in  the  inflammation  ;  if  there  is 
a  pronounced  interstitial  salpingitis  with  great  thickening  of  the 
muscularis,  the  distention  of  the  tubal  canal  is  limited  or  does 
not  occur  at  all. 

If  the  tubal  walls  offer  feeble  opposition  to  the  distention  of 
the  canal,  the  tubal  cyst  may  reach  the  size  of  a  fetal  head  ;  the 
walls  are  very  thin  and  the  tubal  mucosa,  even  in  a  pus-tube,  ex- 
hibits an  atrophy  as  extreme  almost  as  is  seen  in  hydrosalpinx 
or  hematosalpinx. 

The  distention  of  the  tubes  is  confined  mainly  to  the  outer 
two-thirds.  The  inner  third  is  commonly  thickened,  but  not  dis- 
tended.   The  canal  of  the  inner  third  is  reduced  in  caliber  by  the 


Inflammations  of  the  Tubes 


403 


thickened  walls,  by  the  thickened  mucosa,  and  by  actual  stric- 
tures, such  as  are  seen  in  the  male  urethra.  The  canal  is  further 
obstructed  by  the  sharp  angulation  commonly  seen  at  the  junc- 
tion of  the  distended  and  non-distended  portions.  Hence  the 
escape  of  the  pus  into  the  uterine  cavity  or  the  natural  drain- 
age of  a  pyosalpinx  is  almost  impossible.  The  mechanical 
difficulty  of  a  spontaneous  discharge  of  the  tubal  contents  is 
likewise  increased  by  the  displacement  of  the  outer  two-thirds  of 
the  tube  downward  and  backward.  It  does,  however,  sometimes 
occur  and  may  be  favored  by  appropriate  treatment  as  will  be 
indicated    later.      The    tubal    walls    may    be    atrophied    by   the 


Fig.  379. — Salpingitis  isthmica  nodosa  cystica:  f/.  Lumen  of  tube;  c,  cystic 
cavities;  6,  blood-vessels;  m,  circular  muscle-fibers;  s,  subserous  layer.  There  is 
no  communication  between  the  cyst-cavities  and  the  lumen  of  the  tube  (Kleinhans). 


pressure  from  within.  More  commonly  they  are  hypertrophied 
generally  (interstitial  salpingitis)  or  locally  {salpingitis  nodosa 
isthmica^.  There  may  be  multiple  abscesses  in  the  tubal  walls 
in  cases  of  streptococcic  infection  {salpingitis  interstitialis  dis- 
seminata— Zweifel).  The  blood-vessel  walls  in  the  muscularis 
are  thickened  and  show  hyaline  degeneration.  The  usual  ser- 
pentine course  of  the  tube  is  often  converted  in  a  pyosalpinx  into 
a  corkscrew  course.  Knob-like  projections  appear,  therefore, 
upon  the  surface  where  the  spiral  turns  of  the  tube  throw  it  into 
greatest  prominence. 

Gonococci  confine  themselves,  as  already  stated,  mainly  to  the 


404 


The  Fallopian  Tubes 


tubal  mucosa,  but  they  may  invade  the  muscularis  and  even  the 
serosa.  Streptococci  almost  always  penetrate  the  tubal  walls, 
usually  arriving  in  the  tubal  canal  through  its  walls.      The  peri- 


Fig.  380. — Hydrosalpinx. 


Fig.   381. — Hydrosalpinx. 

toneal  surface  is  therefore  commonly  affected  in  streptococcic 
infection,  patches  of  purulent  lymph  clinging  to  the  tubal  serosa 
as  they  do  to  coils  of   intestines  in  general    peritonitis.       The 


Inflammations  of  the  Tubes 


405 


mesosalpinx  or  the  connective  tissue  between  the  layers  of  the 
broad  ligament  just  beneath  the  tubes  is  always  much  thick- 
ened  in   streptococcic   infections,   sometimes  to   a   half    inch   or 


Fig.   382. — Hydrosalpinx,  laid  open. 


Fig.  383. — Hydrosalpinx,  showing  thinning  of  the  tube-wall  and  atrophy  of 
mucous  membrane  :  /,  Lumen  of  tube,  with  mucous  membrane  gone;  t.w,  thinned- 
out  tube-wall  (McConnell  and  J.  C.  Hirst). 

more,  a  condition  which  may  embarrass  the  operator  in  cases  of 
puerperal  infection,  necessitating  drainage  of  the  infiltrated  and 
infected  broad  ligament  and  making  hemostasis  difficult. 

The  localized  hypertrophies  of  the  tubal  wall  named  by  Chiari 


4o6 


The  Fallopian  Tubes 


salpingitis  nodosa  isthviica  form  sharply  circumscribed  knobs  on 
the  uterine  portion  of  the  tube,  from  the  size  of  a  pea  to  that  of 
a  bean.  They  consist  mainly  of  hypertrophied  circular  muscle- 
fibers,  inclosing  a  cystic  space  lined  with  epithelium,  which  is 
obviously  an  offshoot  from  the  tubal  mucosa.  The  latter  in  the 
tubal  canal  is  converted  into  a  sort  of  scar  tissue  ;  the  epithelium 
has  its  cilia. 

Chiari  and  Schauta  explain  these  growths  by  the  excursion 
of  a  portion  of  the  tubal  mucosa  into  the  muscularis,  which  is 
excited   by  the   presence    of  the   foreign    structure  to  continual 


H^^^^^^^xi^^l 

1 

^^^             '^^^ 

1 

^^B^m^^i 

1 

Fig.  384. — Hematosalpinx. 


contraction  and  so  experiences  a  localized  hypertrophy.  Evi- 
dences of  chronic  tubal  inflammation  always  accompany  these 
growths.  They  were  formerly  described  under  the  name  of 
tubal  myomata  or  fibroids. 

Hydrosalpinx^  is  a  form  of  tubal  inflammation  in  which  the 
abdominal  o.stium,  possibly  the  uterine  ostium  also,  is  closed  and 
in  which  there  is  an  accumulation  of  serous  fluid  or  thin  mucus 
in  the  tubal  canal,  usually  in  its  outer  two-thirds.  Ordinarily  the 
di.stention  of  the  tubes  is  considerable  ;  their  walls  are  very  thin 

'  Synonyms  :   hydrops  tuboe,  sacrosalpinx  serosa,  dropsy  of  the  tubes. 


Hydrosalpinx 


407 


and  atrophic.     They  present  the  appearance  of  a  thin-walled  cyst 
with  the  clear  liquid  contents  showing  through  the  walls. 

There  is  always  a  perisalpingitis  in  eveiy  case  of  hydrosalpinx 
which  closes  the  abdominal  ostium  ;  there  need  not  be,  and  often 


Fig.   385. — Hematosalpinx 


Fig.   386. — Hematosalpinx:  a.v.  Atrophied   plications  of  mucous  membrane;    h. 
blood-clot;   /,  lumen  of  the  tube;  t,  tube-wall  (McConnell  and  J.  C.  Hirst). 


is  not,  any  other  inflammatory  action  of  the  tube  itself.  There 
must  also  be  a  closure  or  obstruction  of  the  uterine  ostium  or 
the  isthmus  of  the  tube,  otherwise  the  thin  serous  contents 
would  drain  into  the  uterus.      This  sometimes  happens  {hydrops 


4o8 


The  Fallopian  Tubes 


tubes  profluens),  but  the  sac  usually  refills.  The  muscularis  and 
the  mucosa  of  the  tube  exhibit  an  extreme  degree  of  atrophy. 
The  latter  is  a  thin  single  layer  of  epithelium  flattened  by  pres- 
sure  to   cuboidal    or   endothelial-like    cells.      The   plications  are 


Fig.  387. — Torsion  of  Fallopian  tube.  Diagrammatic.  The  ovarian  and  broad 
ligaments  are  necessarily  involved  in  the  torsion.  In  this  case  the  tube  and  ovary 
were  lifted  out  of  the  abdomen  by  light  traction.    There  was  no  necessity  for  a  ligature. 


Fig.   388. — Destruction  and  complete  absorption  of  the  outer  two-thirds  of  the  tube 
and  of  the  ovary  following  torsion  (University  Hospital). 


represented  by  slightly  elevated  lines  joining  at  the  site  of  the 
abdominal  ostium  like  the  groins  of  interlacing  arches. 

In  exceptional  cases  the  tubal  walls  in  hydrosalpinx  are 
thickened  to  a  marked  degree.  The  quantity  of  fluid  in  such 
instances  is  small.  Hydrosalpinx  is  usually  bilateral.  There  is 
a  previous  history  of  puerperal  infection  in  the  majority  of  cases. 


Tuberculosis  of  the  Tubes  409 

The  size  of  the  tumors  is  commonly  moderate,  but  the  liquid 
contents  have  measured  a  liter  or  more. 

Hematosalpinx  is  an  accumulation  of  blood  in  a  tube,  closed 
at  its  abdominal  end  and  obstructed  or  closed  at  the  uterine 
ostium  or  isthmus.  ^  The  origin  of  the  blood  might  possibly  be  a 
hemorrhage  from  the  ovary  or  a  reflux  from  the  uterine  cavity, 
but  it  is  practically  always  from  the  tubal  mucosa,  the  result  of 
tubal  menstruation,  extreme  congestion,  or  inflammation.  The 
hematosalpinx  associated  with  gynatresia  possesses  particular 
interest  for  the  gynecologist  on  account  of  its  hability  to  infection 
and  to  rupture  with  infection  of  the  peritoneum,  which  a  simple 
blood  effusion  would  not  do.  The  explanation  of  this  phenomenon 
usually  offered  is.  that  a  hematosalpinx  is  only  found  in  an  ac- 
quired atresia  ;  that  it  is  the  result  of  infection  and  inflammation 
of  the  tubes,  and  that  it  may  precede  the  acquired  atresia 
of  the  lower  genital  canal.  But  the  author  and  others  have 
observed  an  enormous  hematosalpinx  in  cases  of  congenital 
atresia.  It  is  likely  that  every  hematosalpinx  is  the  result  of 
an  inflammatory  process,  if  not  of  the  tube  itself,  at  least  of  the 
structures  surrounding  the  abdominal  ostium.  The  blood  may 
exude  from  the  tubal  mucosa  as  it  does  from  the  endometrium,  or 
it  may  escape  from  ruptured  blood-vessels.  The  cause  of  the 
hemorrhage  is  a  tubal  menstruation  or  an  acute  and  extreme 
congestion  of  the  tubes  from  torsion  or  any  of  the  causes  already 
enumerated  obstructing  the  circulation.  Torsion  is  most  apt  to 
affect  a  tube  already  distended  ;  hence  a  h3'drosalpinx,  which  with 
its  thin  walls  is  likely  to  be  twisted  on  itself,  may  thus  be  con- 
verted into  a  hematosalpinx.  The  physical  peculiarities  of  the 
latter  closely  resemble  the  former ;  there  is  the  same  distention 
of  the  outer  two-thirds  of  the  tube,  possibly  to  the  same  degree, 
the  same  thin  atrophic  walls  and  the  atrophied  mucosa.  The 
color  of  a  hematosalpinx  is  naturally  different,  and  after  the  evac- 
uation of  the  blood  the  lining  of  the  tubal  canal  is  stained  brown 
by  the  blood  pigment. 

Tuberculosis  of  the  tubes  is  commoner  than  in  any  other 
portion  of  the  genital  tract.  ^  In  4470  postmortem  examinations 
tuberculosis  of  the  tubes  was  found  53  times.  V.  Rosthorn  (103), 
Martin  (620),  and  Williams  (91)  in  814  cases  of  salpingitis 
found  tuberculosis  in  29.  ^      Menge  **    in  70  cases  of  pyosalpinx 

1  Chrysopathes  reports  a  case  of  bilateral  adenomyoma  of  the  tubal  isthmus 
obstructing  the  tubal  canals  ("  Zeitschr.  f.  Geburtsh.  u.  Gyn.,"  xliv,  3). 

'^  Williams,  "Tuberculosis  of  the  Female  Generative  Organs,"  "Johns  Hopkins 
Hospital  Reports,"  1892,  iii. 

^  Veit's  "Handbuch  der  Gyn.,"  vol.  3^,  p.  724. 

*  "  Ueber  tuberculose  Pyosalpinx,"  "Verhandl.  d.  Ges.  f.  Geb.,"  "Centralbl.  f. 
Gyn.,"  1894,  p.  24. 


4IO 


The  Fallopian  Tubes 


found  tuberculosis  in  7.  In  22  cases  of  salpingitis  in  the  author's 
service,  examined  in  the  pathological  laboratory  of  the  Howard 
Hospital  in  the  first  six  months  of  1902,  4  were  tuberculous. 
Tuberculosis  of  the  tubes  is  almost  always  bilateral.  The  tubercu- 
lous infection  is  either  primary  or  secondary.  The  tubercle  bacilli 
in  secondary  infection,  which  is  much  the  commoner,  are  derived 
from  some  tubercular  focus  elsewhere  in  the  body  ;  in  primary 
infection  they  are  introduced  from  without  and  first  settle  in  the 
tubes.  There  can  be  an  ascending  or  a  descending  infection.  The 
latter  from  the  peritoneum  is  always  secondary,  the  former  from 
the    uterine    cavity   can   be    either    primary   or   secondary.      A 

secondary    infection    may 
be  metastatic  by  way  of 
the     blood-vessels     from 
some  focus  situated  in   a 
distant  part  of  the  body. 
It  may  be  due  to  contig- 
uity, as  from  a  tuberculous 
ulcer  in  the  bowel  which 
has  become    adherent   to 
the   tube.      It    is   claimed 
that  a  primary  infection  of 
the  tubes  may  occur  from 
the    blood    or    lymphatic 
current,  the  bacilli  leaving 
no  trace  of  infection  at  the 
point  of  their  original  en- 
trance into  the  body.     A 
small  ulcer  or  abrasion  at 
the    vaginal     introitus    is 
supposed   to   be  the  most 
frequent  point  of  entrance 
in  such  cases.      Mixed  infections  of  the  tubes  have  been  noted. 
Whether    gonococci,    streptococci,   and   colon  bacilli   make    the 
tube  which    they  have  infected  more  susceptible    to  tubercular 
infection,  or  vice  versa,  is  not  yet  determined.      The  tuberculous 
tube  in  an  advanced   stage  of  the    inflammation    is   thickened, 
distended,  tortuous,   hard  and  knobby  in  feel.     The  peritoneal 
surface  may  be   thickly  peppered  with   visible  tubercles   or  may 
be  flecked  with  cheesy  deposit.      The  abdominal  ostium  may  be 
closed  or  open  ;  in  the  latter  case  pus  of  a  varying  consistency 
from  a  thin,  serous  discharge  to  a  thick,  cheesy  material   may 
ooze  out  of  it.      The  mucous  membrane  is  thickly  studded  with 
tubercles,   may  be  necrotic,  even  exfoliated.      The  tubal  wall  is 
thickened,  often  markedly  so,  and  in  its   whole   length  from  its 


Fig.   389. — Tuberculous  pyosalpinx. 


Tuberculosis  of  the  Tubes  411 

insertion  in  the  uterus.  The  tube  may  have  the  ordinary  shape 
of  a  pus-tube  with  the  greatest  distention  in  the  outer  two-thirds, 
or,  as  in  one  of  the  author's  cases,  the  distention  may  affect  only 
the  outer  third,  which  suddenly  expands  in  a  spherical  shape,  in 
sharp  contrast  with  the  inner,  unaffected  two-thirds  of  the  tube. 
In  tuberculous  tubes  more  than  in  any  other  form  of  salpingitis 
the  tube-wall  is  knobby  or  lumpy  in  feel  from  localized  hyper- 
trophy  or  infection  of  the  muscularis. 

Williams  divides  tubal  tuberculosis  into  miliary,  chronic 
diffuse,  and  chronic  fibroid  forms.  Another  division  is  made  into 
an  acute  form,  in  which  there  is  a  rapid  destruction  of  both  the 
mucosa  and  muscularis,  and  a  chronic  form,  in  which  there  is  the 
gradual  development  of  a  tubercular  pus-tube.  In  the  acute 
form  there  is  round-cell  infiltration  of  the  mucosa,  numerous 
tubercles  with  comparatively  few  giant- cells,  but  many  tubercle 


Fig.   390. — Primary  carcinoma  of  the  tube:  u.  Uterine  end;  a,  abdominal  end 

(Kleinhans). 

bacilli.  In  the  chronic  form  the  tubercles  contain  many  giant- 
cells,  but  fewer  bacilli.  The  mucosa  may  show  a  vegetating 
growth  so  luxuriant  as  to  simulate  malignancy.  As  in  all  forms 
of  chronic  inflammation  of  the  tubal  mucosa,  there  are  ad- 
hesions of  the  plications  and  the  formation  of  cyst  spaces  under- 
neath. 

Tubercles,  giant-cells,  and  bacilli  may  be  found  in  the  muscu- 
lar tubal  walls  as  well  as  in  the  mucosa. 

The  termination  of  a  tubercular  salpingitis  may  be  spontane- 
ous cure  by  calcification  of  the  tubal  contents,  or  encapsulation 
either  by  dense  adhesions  or  by  enormously  thickened  tubal 
walls.  There  may  be  fatal  infection  of  the  whole  organism  or  of 
a  distant  organ  by  metastasis.  There  may  be  infection  of  neigh- 
boring structures  by  contiguity,  as  the  uterus,  the  peritoneum,  or 
the  intestines. 

In   syphilis  the  tubes   may  be  thickened,  tortuous,  infiltrated 


412 


The  Fallopian  Tubes 


with  round  cells,  and  the  seat  of  gumma.  The  tube  has  been 
found  inflamed  in  two  cases  in  consequence  of  actinomycosis. 
Eighty  cases  of  echinococctis  infection  of  the  tubes  have  been 
collected.^ 

Neoplasms  of  the  Tubes. — Polyps,  papillomata,  sarcomata, 
fibromyomata,  dermoids,  lipomata,  fibromyomata  cystosa,  carcino- 
mata,  lymphangioma,  deciduoma,  enchondroma,  and  cysts  have 
been  observed.  ^  Carcinoma  of  the  tube  is  not  infrequently  sec- 
ondary to  malignant  disease  of  the  uterus  or  ovary.  It  may 
be  primary.  It  is  derived  from  the  tubal  mucous  membrane 
and    takes    a   papillary  form.       Inflammatory  disease    seems  to 


Fig. 


391. — Papillary  carcinoma  of  the   Fallopian  tube:  e,  Hyperplasia  of  columnar 
epithelium  ;  s,  fibrous  stroma  of  villi  (McConnell  and  J.  C.  Hirst). 


have  a  causative  relation  with  it.  The  situation  is  usually  in  the 
middle  or  outer  third  of  the  tube.  In  consistence  the  tumor  is 
always  medullary. 

Bilateral  carcinoma  of  the  tubes  has  been  noted  as  a  rare 
occurrence.  According  to  Kleinhans,  5  cases  of  tubal  sarcomata 
have  been  reported.  Sanger^  collected  6  cases  of  benign  papil- 
lomata of  the  tubal  mucous  membrane.  Gonorrhea  seems  to  be 
a  predisposing  cause. 


1901. 


^  Veit's  "  Handbuch,"  p.  739,  vol.  3^. 

2  Quenu  et  Longuet,  "Des  Tumeurs  des  Trompes,"  "  Rev.  de  Chir.,"  Oct.  10, 

2  "  Verhandl.  d.  Ges.  f.  Geb.  zu  Leipzig,"  1890-91,  p.  30. 


Symptoms  of  Tubal  Disease  413 

Symptoms  of  Tubal  Disease. — The  most  prominent  subjective 
symptom  is  pain,  usually  localized  in  the  groin  above  the 
middle  of  Poupart's  ligament.  If  both  tubes  are  alike  diseased 
the  pain  is  more  acutely  felt  on  the  left  side.  If  the  disease  is 
unilateral  the  suffering  is  confined  to  the  side  diseased.  The  pain 
is  variously  described  as  shooting,  stabbing,  boring,  burning,  or 
an  intense  ache.  In  acute  salpingitis  the  pain  is  usually  lancinat- 
ing. The  patient  walks  with  a  cautious  tread,  the  body  is  bent 
forward,  and  the  hands  are  often  held  outspread  over  the  lower 
abdomen  as  if  to  protect  it.  The  statement  is  made  that  a  sud- 
den turn  in  bed,  a  cough  or  sneeze,  coitus,  or  a  sudden  jolt  or 
jar  from  any  cause  occasions  a  sharp  stab  of  pain.  There  is 
almost  invariably  an  exacerbation  of  pain  in  the  period  of  pre- 
menstrual congestion,  relieved  when  the  flow  appears,  returning 
in  aggravated  form  when  it  ceases.  The  pain,  therefore,  is  great- 
est before  and  after  menstruation.  There  is  usually  backache, 
which  may  be  the  predominant  symptom.  The  pain,  instead  of 
being  localized,  may  be  manifested  in  distant  regions  as  headache, 
pain  in  the  nape  of  the  neck,  the  top  of  the  head,  the  breast,  the 
axilla,  or  the  epigastrium.   The  rectum  is  frequently  the  seat  of  pain. 

There  is  often  a  history  of  leukorrhea  on  account  of  the  infec- 
tion of  the  cervical  and  corporeal  endometrium  which  precedes, 
accompanies,  or  follows  the  infection  of  the  tubal  mucosa.  Occa- 
sionally the  discharge  emanates  from  the  tubes  themselves,  in 
intermittent  gushes  of  pus  or  serum  {liydrops  tiibcB  profliiens). 
Menorrhagia  is  a  common,  almost  a  constant  accompaniment  of 
tubal  inflammatory  disease.  The  period  is  lengthened,  the  inter- 
val is  shortened,  and  the  quantity  of  blood  lost  is  abnormally 
great.  In  rare  instances  the  menorrhagia  becomes  a  metror- 
rhagia so  profuse  and  long  continued  as  to  cause  a  profound 
anemia,  and  actually  to  threaten  the  woman's  life.  In  excep- 
tional cases  the  menstruation  may  be  scanty  or  there  may  be 
amenorrhea  on  account  of  uterine  anemia,  because  the  inflamed 
tubes  attract  blood  from  the  uterus  to  themselves  or  by  reason  of 
atrophic  changes  in  the  appendages  or  uterus. 

There  may  be  and  usually  is  a  history  of  neurasthenia,  diges- 
tive disturbances,  loss  of  weight,  and  failing  strength.  The 
patient  with  diseased  tubes  rarely  presents  an  appearance  of  good 
health.  She  is  thin,  has  a  bad  color,  an  anxious  expression,  and 
looks  prematurely  aged.  She  may  present  the  waxy  pallor  of 
extreme  anemia  or  a  cachectic  appearance  from  toxemia,  suggest- 
ing malignancy  or  tuberculosis. 

In  exceptional  instances  inflamed,  distended,  and  adherent 
tubes  have  no  apparent  effect  upon  the  woman's  general  health 
and  may  cause  wonderfully  little  local  disturbances. 


414  The  Fallopian  Tubes 

On  abdominal  palpation  the  patient  winces  under  deep  pres- 
sure over  Poupart's  ligaments  and  may  be  unable  to  endure  the 
slightest  pressure  in  that  region. 

On  a  bimanual  vaginal  and  abdominal  examination  it  is  usual 
to  find  the  diseased  tube,  or  tubes,  distended,  thickened,  prolapsed 
into  Douglas's  pouch,  and  adherent.  In  acute  cases  the  lightest 
touch  of  the  internal  finger  in  the  posterior  vaginal  vault  elicits  a 
shriek  of  pain.  There  is  nothing  so  sensitive  in  the  lower  abdo- 
men as  an  acute  pyosalpinx  with  involvement  of  the  ovary,  except 
a  tubal  gestation  sac.  In  chronic  cases  there  is  almost  always 
exaggerated  tenderness,  but  rarely  agonizing  pain  on  palpation. 
From  the  prolapse  of  the  fimbriated  extremity  of  the  tube  and  of 
the  ovary  with  the  consequent  drag  upon  the  cornua  of  the  uterus 
by  means  of  the  tubes  and  the  ovarian  ligaments  there  is  almost 
always  some  backward  displacement  of  the  uterus,  which  is  usually 
fixed  about  midway  between  ante-  and  retroflexion,  being  prevented 
from  turning  completely  over  backward  by  the  combined  bulk 
of  the  distended  tubes,  the  ovaries,  and  the  inflammatory  exudate 
in  Douglas's  pouch.  If  the  bulk  of  the  inflammatory  mass  is 
not  great,  there  may  be  and  usually  is  complete  retroflexion  with 
the  accompanying  physical  signs  of  a  chronic  metritis,  a  con- 
gested, soft,  and  enlarged  uterus.  The  position  of  the  uterus, 
however,  is  not  necessarily  faulty.  It  may  be  in  a  position  of 
normal  anteflexion,  may  be  unaltered  in  size,  or  may  be  mark- 
edly atrophic.  The  tubes  themselves  may  occupy  a  normal 
position,  may  lie  in  front  of  the  uterus,  between  it  and  the  blad- 
der, or  may  run  a  course  obliquely  upward  and  forward  to  the 
iliac  fossae. 

If,  as  is  usually  the  case,  they  are  prolapsed  into  Douglas's 
pouch  and  are  distended,  they  may  be  so  intimately  adherent 
to  the  sides  and  back  of  the  uterus  as  to  be  distinguished 
with  difficulty  from  the  uterine  corpus  ;  but  a  careful  bimanual 
examination  almost  always  enables  the  experienced  specialist 
to  outline  the  uterus  and  to  differentiate  the  more  globular, 
softer,  and  more  sensitive  structures  adherent  to  it.  The  adhe- 
sions may  be  so  intimate,  however,  and  the  tubal  wall  may  be  so 
dense  and  hard  that  an  old  pus-tube  is  regarded  as  a  sub- 
peritoneal fibroid.  There  is  no  gynecologist  of  large  experience 
who  has  not  made  this  mistake.  If  the  tube  lies  approxi- 
mately in  its  normal  position,  it  is  easy,  as  a  rule,  to  roll  it 
between  the  examining  fingers  and  so  to  determine  the  amount 
of  distention,  the  infiltration  of  its  wall,  the  density  and  extent  of 
the  inflammatory  exudate  or  adhesions  around  it.  Even  if  it  is 
prolapsed  into  Douglas's  pouch  and  constitutes  there  a  con- 
glomerate inflammatory  mass  with  the  ovary  and  plastic  exudate. 


Treatment  of  Tubal  Inflammation  415 

it  is  not  ordinarily  difficult  to  trace  its  course  from  the  uterine 
cornu  to  its  abdominal  extremity  and  to  determine  with  approxi- 
mate accuracy  its  shape,  size,  and  the  thickness  of  its  walls.  In 
the  course  of  an  examination  which  often  immediately  detects- 
the  presence  of  tubal  inflammatory  disease,  certain  facts  of  im- 
portance in  a  differential  diagnosis  should  be  carefully  noted.  If 
the  tube  is  distended  its  abdominal  orifice  is  almost  certainly- 
closed  and  its  uterine  extremity  is  probably  occluded  or  ob- 
structed. It  must  be  distended  by  pus,  blood,  or  serum.  If  by  the 
first  the  tubal  walls  are  usually  much  thickened  and  the  sensitive- 
ness is  great,  the  greater  the  more  acute  the  process.  There  is 
not  so  much  tenderness  in  hydro-  and  hematosalpinx ;  in  these 
conditions  the  tube-walls  are  commonly  very  thin  and  a  distinct- 
fluctuation  may  be  appreciated.  If  the  tube  is  very  much  thick- 
ened as  it  leaves  the  uterine  cornu,  if  it  is  strikingly  knobby  in 
feel,  the  suspicion  of  tuberculosis  must  be  entertained.  The 
history  of  the  patient  and  signs  of  tuberculosis  elsewhere,  es- 
pecially in  the  visible  genitalia  or  in  the  peritoneum  (encysted 
ascites),  strengthen  the  suspicion.  On  the  contrary,  a  history 
of  gonorrhea  or  signs  of  such  infection  in  the  genital  tract  point 
to  a  gonorrheal  pus-tube. 

A  rounded  node  or  nodes  on  the  isthmus  indicate  the  possi- 
bility of  salpingitis  isthmica  nodosa,  but  the  folds  of  a  tortuous 
tube  may  simulate  this  condition  exactly  to  the  sense  of  touch.  A 
tube  thickened,  hard  in  feel,  rolling  stiffly  under  the  fingers,  but  not 
distended,  indicates  chronic  interstitial  salpingitis  without  closure 
of  the  abdominal  ostium.  The  rarer  tumors  of  the  tube  which, 
have  been  mentioned  are  only  diagnosticated  by  abdominal 
section,  the  removal  of  the  tube  and  its  careful  pathological  ex- 
amination. A  solid  tumor,  however,  excessively  painful,  asso- 
ciated with  cachexia  and  ascites,  indicates  malignancy. 

The  treatment  of  tubal  inflammation  is  preventive,  palliative, 
or  curative. 

The  preventive  treatment  is  a  serious  problem  confronting  the 
physician  in  his  daily  work,  but  often  beyond  his  control.  If  the 
social  evil  and  its  attendant  risk  of  venereal  infection  could  be 
eliminated,  the  large  majority  of  tubal  inflammations  in  women 
would  disappear.  It  has  been  estimated  that  there  are  at  the 
present  time  a  million  men  with  gonorrhea  in  the  United  States. 
From  his  experience  in  dispensary,  hospital,  and  private  practice 
the  author  is  convinced  that  a  prostitute  is  certain  to  be  infected 
with  gonorrhea  within  a  few  weeks  of  the  time  she  begins  her 
career.  The  number  of  innocent  women  that  one  such  creature 
can  indirectly  infect  is  incalculable,  but  it  must  be  very  large. 
The  physician  can  accomplish   some  good  perhaps  by  warning; 


41 6  The  Fallopian  Tubes 

young  men  of  the  practical  certainty  of  venereal  infection  from 
women  of  loose  character,  and  by  combating  the  prevalent  idea 
that  gonorrhea  is  a  small  matter,  easily  cured,  and  with  no  per- 
manent results.  The  man  who  is  known  to  have  gonorrhea 
should  be  warned  against  matrimony  until  repeated  bacteri- 
ological examinations  of  the  urethral  discharge  show  that  it  is 
sterile.  The  man  already  married  who  contracts  gonorrhea  must 
be  clearly  informed  of  the  danger  of  infecting  his  wife,  and 
urgently  warned  against  subjecting  her  to  the  possibility  of  it 
until  ample  time  has  elapsed  after  apparently  successful  treatment 
and  until  repeated  bacteriological  examinations  have  shown  that 
his  urethral  discharge  is  no  longer  infectious.  The  physician  is 
Tiot  infrequently  in  the  painful  position  of  knowing  that  a  hus- 
band is  gonorrheic,  of  recognizing  the  disease  in  the  wife,  pos- 
sibly in  a  mild  form,  and  of  realizing  the  necessity  of  avoiding  a 
fresh  or  more  virulent  infection.  Great  as  his  indignation  must 
be  at  the  criminal  indifference  or  ignorance  of  a  man  who  will 
subject  his  wife  to  the  risk  of  venereal  infection,  strongly  as  his 
sense  of  duty  to  his  patient  must  impel  him  to  warn  her  of 
the  danger  she  incurs,  the  physician's  lips  must  often  be  sealed. 
He  can  only  endeavor  to  obtain  protection  for  his  patient  by  a 
private  appeal  perhaps  to  the  husband,  by  forbidding  coitus  as 
injurious  to  the  woman's  general  health  or  local  condition,  or 
by  instituting  such  local  treatment — for  example  the  continuous 
use  of  tampons  for  months  at  a  time — as  will  effectually  pre- 
vent it.  An  injudicious  word,  a  betrayal  of  information  obtained 
by  a  medical  examination,  may  disrupt  a  family,  separate  husband 
and  wife  and  a  father  from  his  children.  However  richly  the 
man  may  deserve  such  punishment,  it  is  not  the  physician's 
function  to  inflict  it. 

The  other  most  frequent  cause  of  tubal  inflammation,  puer- 
peral infection,  is  more  directly  under  medical  control.  The 
proper  treatment  of  abortion,  by  an  aseptic  curettage,  an  adequate 
aseptic  technic  in  the  management  of  labor,  including  the  invari- 
able use  of  rubber  gloves  for  internal  examinations  and  manipu- 
lations, should  almost  banish  puerperal  infection  and  its  conse- 
quences from  medical  practice.  Criminal  abortion  still  remains, 
however,  as  a  prolific  source  of  tubal  disease  beyond  the  repu- 
table physician's  control. 

The  palliative  treatment  of  tubal  inflammations  is  indicated 
in  the  acute  stage,  in  the  chronic  stage  if  the  uterus  is  retro- 
verted  and  the  inflamed  tubes  and  ovaries  are  prolapsed  into  and 
adherent  in  Douglas's  pouch,  both  to  the  uterus  and  the  rectum, 
and  in  exacerbations  of  an  old  tubal  inflammation.  If  there  is  a 
very  large  accumulation  of  pus,  blood,  or  serum  in  the  tubes,  or 


Treatment  of  Tubal  Inflammation  417 

if  the  latter  are  so  situated  laterally  that  they  are  inaccessible  to 
manipulation  or  pressure  through  the  vaginal  vaults,  local  palli- 
ative treatment  is  usually  waste  of  time. 

The  objects  of  palliative  treatment  are  to  allay  acute  inflam- 
mation, to  lessen  the  pain,  to  correct  the  malposition  of  the  tubes 
and  the  retroversion  of  the  uterus  that  usually  accompanies  it,  to 
secure  an  evacuation  of  the  tubal  contents,  to  stretch  or  cause 
the  absorption  of  the  adhesions  around  the  tubes  and  to  neigh- 
boring organs,  especially  the  rectum  ;  to  promote  the  absorption 
of  the  infiltration  of  the  tubal  walls  ;  to  control  the  metrorrhagia 
that  is  often  associated  with  salpingitis,  and  as  a  secondary  object 
to  make  conception  possible  in  a  woman  who  is  sterile  as  long  as 
the  malposition  of  the  tubes,  the  closure  of  the  abdominal  ostia, 
and  their  envelopment  in  exudate  continue. 

All  of  these  objects  may  occasionally  be  attained  in  cases 
that  at  first  sight  appear  most  discouraging. 

The  means  by  which  they  may  be  accomplished  are  the  use 
of  tampons,  hot-water  douches,  abdominal  massage,  hot  or  cold 
applications  to  the  lower  abdomen,  and  curettage. 

In  acute  salpingitis  with  fever  and  intense  pain,  rest  in  bed  is 
required.  Hot  douches  of  a  gallon  of  water  at  a  temperature  of 
I  I5°-I20°  F.  should  be  administered  night  and  morning.  After 
the  douche  a  lamb's-wool  tampon  saturated  with  boroglycerid 
or  with  ichthyol  4  parts,  glycerin  6  parts,  should  be  inserted  in 
the  vagina  and  pushed  well  up  into  the  vault.  Another  tampon 
dusted  with  dry  boracic  acid  powder  should  be  next  inserted  to 
keep  the  first  in  place.  The  ice-water  coil  on  the  lower  abdomen 
usually  gives  the  greatest  comfort  and  is  most  efficacious  as  an 
external  application. 

If  cold  is  uncomfortable  to  the  patient  or  fails  to  relieve  the 
pain,  moist  heat  in  the  shape  of  a  large  flaxseed-meal  poultice 
covered  on  its  inner  side  with  a  single  layer  of  gauze  and  pro- 
tected externally  by  waxed  paper  or  oiled  silk  should  be  substi- 
tuted. A  free  evacuation  of  the  bowels  must  be  secured  by  the 
milder  salines,  Rochelle  salts,  Carlsbad  water  and  Sprudel's  salts, 
Hunyadi  water,  Kutnow's  salts,  and  the  like.  A  few  days  of 
this  treatment  usually  results  in  a  disappearance  of  fever,  a  relief 
of  pain,  and  a  wonderful  improvement  in  the  patient's  general 
condition.  It  is  then  possible  to  decide  whether  an  operation  is 
indicated  or  whether  all  traces  of  the  inflammation  have  dis- 
appeared. In  the  former  case  the  outlook  is  much  more  favor- 
able for  the  patient  than  if  the  operation  were  undertaken  in  the 
midst  of  an  acute  infectious  process.  In  the  latter  case  no  fur- 
ther treatment  is  required. 

In  acute  exacerbations  of  an  old  salpingitis  the  same  treat- 
27 


41 8  The  Fallopian  Tubes 

ment  is  indicated,  but  complete  subsidence  of  the  inflammation 
and  disappearance  of  the  tubal  inflammation  are  not  to  be  expected. 
The  palliative  treatment  in  such  a  case  should  usually  be  pre- 
paratory to  an  operation.  In  a  chronic  case  perhaps  of  long 
continuance,  possibly  in  a  more  recent  case  after  the  acute  symp- 
toms have  subsided,  leaving  displaced,  adherent,  distended  tubes, 
palliative  treatment  may  be  indicated  for  several  reasons  :  The 
patient  may  demand  the  exhaustion  of  every  other  means  of 
treatment  before  resort  to  an  operation  ;  there  may  be  special 
reasons  why  an  operation  is  undesirable  in  a  given  instance,  as 
the  existence  of  kidney  disease  or  a  profound  reduction  of  the 
general  health  and  strength  ;  or  the  physician  may  desire  to  con- 
vince himself  and  his  patient  that  nothing  but  an  operation  will 
give  satisfactory  results. 

The  kind  of  chronic  case  promising  the  most  from  palliative 
treatment  is  one  in  which  the  tubes  and  ovaries  are  displaced  into 
and  adherent  in  Douglas's  pouch  both  to  the  uterus  and  the 
rectum  and  in  which  there  is  a  retroflexion  of  the  uterus.  Before 
undertaking  the  treatment  of  such  a  case  the  patient  should  be 
clearly  informed  of  the  following  facts  :  The  treatment  is  tedious  ; 
it  is  often  trying  to  the  nervous  system  ;  its  results  are  uncertain  ; 
it  is  possible  that  the  local  disturbance  involved  in  the  treatment 
may  aggravate  rather  than  improve  the  inflammatory  condition  ; 
it  may  be  necessary  to  give  it  up  and  to  make  a  choice  between 
enduring  the  symptoms  of  the  pelvic  inflammation  or  of  submit- 
ting to  an  operation  ;  and  finally,  after  weeks  of  patient  effort 
on  the  part  of  physician  and  patient,  the  result  may  be  dis- 
appointing and  an  operation,  after  all,  be  required  to  relieve  the 
symptoms.  On  the  contrary,  in  exceptional  cases  there  is  a 
complete  symptomatic  cure  and  such  an  improvement  in  the 
physical  conditions  locally  that  it  is  difficult  to  find  evidences 
of  the  grave  pelvic  inflammation  which  existed  when  the  treat- 
ment was  begun.  Pregnancy  may  occur  after  improvement 
in  the  position  and  condition  of  the  tubes  and  may  com- 
plete the  cure  by  the  stretching  or  absorption  of  the  remain- 
ing adhesions.!  -pj^g  local  palliative  treatment  to  secure  such 
results  is  simply  the  use  of  long-continued  pressure  by  elastic 
lamb's-wool  tampons  packed  tightly  into  the  vaginal  vaults 
and  canal.  The  patient  is  put  in  the  knee-chest  posture.  A 
Sims'  speculum  is  inserted  and  held  by  a  nurse.  A  lamb's-wool 
tampon  is  dipped  into  a  clean  glass  dish  filled  with  boracic  acid 
and  is  packed  somewhat  forcibly  into  the  posterior  vaginal  vault 
by  means  of   an  Emmet's  curetment  forceps  which  is  held  with 

1  Every  year  the  author  secures  such  results  in  his  office  practice,  though  it  must 
be  admitted  that  they  are  exceptional. 


Treatment  of  Tubal  Inflammation  419 

its  convexity  upward — that  is,  upside  down.  Tampons  are  packed 
in  one  after  the  other  until  the  posterior  vaginal  vault  and  the 
rest  of  the  vaginal  canal  to  within  an  inch  of  its  orifice  are 
filled  as  tightly  as  possible.  The  woman  rests  for  half  an  hour 
afterward.  She  removes  the  tampons  forty-eight  hours  later 
by  the  strings  attached  to  them  and  takes  a  douche  of  boracic 
acid  (5ij  to  Oij)  just  before  her  return  to  the  physician's  office. 
On  the  odd  days  when  the  treatment  is  not  being  carried  out, 
deep  abdominal  massage  is  an  advantage.  This  treatment  is  kept 
up  continuously  for  six  to  twelve  weeks  except  during  men- 
struation. The  general  health,  the  blood,  the  diet,  and  the 
bowels  must  naturally  receive  attention.  Systematic  exercise 
in  the  open  air  with  regular  periods  of  rest  in  the  recumbent 
posture  twice  a  day  should  be  ordered.  The  steady  pressure  on 
the  uterus  and  tubes,  the  improvement  in  the  lymphatic  and 
blood  circulation  due  to  the  massage,  may  elevate  the  tubes 
and  uterus  to  a  normal  position,  may  evacuate  the  former  of  their 
contents,  may  stretch  or  cause  the  absorption  of  the  adhesions 
to  the  bowel  which  are  often  the  source  of  the  greatest  discom- 
fort, and  may  restore  patency  to  the  tubes,  as  is  evidenced  by 
subsequent  impregnation. 

The  internal  massage  proposed  by  Thure  Brandt  has  not 
proved  satisfactory  ^  and  there  are  obvious  objections  to  its 
employment. 

Electricity  in  pelvic  inflammation  is  illogical  and  proved  inef- 
ficacious in  a  two  years'  trial  some  time  ago  in  the  author's 
hands. 

If  a  persistent  trial  of  the  local  treatment  described  above  is 
not  successful,  the  patient  must  choose  between  the  endurance  of 
her  symptoms  or  relief  by  an  operation.  Curettage  is  rarely  indi- 
cated in  salpingitis,  but  it  has  its  uses.  There  are  cases — excep- 
tional, it  is  true — in  which  metrorrhagia  is  the  predominant 
symptom,  reducing  the  patient  to  an  extreme  degree.  Even  if 
an  abdominal  operation  is  determined  upon,  in  such  a  case  it  is 
safer  if  the  patient's  anemia  is  first  improved.  Moreover,  the 
removal  of  the  endometrium,  especially  about  the  uterine  ostia 
of  the  tubes,  followed  by  a  firm  tamponade  of  the  vagina,  has 
resulted  in  a  discharge  of  the  tubal  contents  into  the  uterus  and 
the  disappearance  of  the  symptoms  of  salpingitis.  There  is 
unquestionably  some  danger  of  relighting  a  fresh  inflammation 
of  the  tubes  and  pelvic  peritoneum  by  the  use  of  a  curet  in  the 
uterus  with  inflamed  tubes  alongside  of  it.     The  operation,  there- 

1  I  have  given  this  method  a  thorough  trial  by  referring  patients  to  graduates  of 
the  Copenhagen  Institute,  but  the  results  were  disappointing  and  not  a  few  patients 
found  the  treatment  unendurable. 


420  The  Fallopian  Tubes 

fore,  should  only  be  undertaken  in  a  well-appointed  clinic,  with 
the  understanding  that  it  might  be  necessary  to  follow  it  by  a 
vaginal  or  abdominal  section  iL  symptoms  of  fresh  inflammation 
appear.  The  danger,  liowever,  is  not  great  in  a  carefully  con- 
ducted curettage.  The  author  has  not  yet  experienced  it  in  the 
few  cases  under  his  care  demanding  this  treatment. 

The  curative  treatment  of  salpingitis  is  usually  operative.  It 
is  indicated  in  very  large  pus-tubes  such  as  are  illustrated  in 
figures  369  to  372  ;  in  cases  with  so  much  suffering  that  the 
patient  urgently  demands  relief;  after  the  failure  of  palliative 
treatment;  in  women  who  can  not  afford  invalidism,  which  in  the 
poorer  classes  may  mean  pauperism ;  in  patients  who  are  not 
willing  to  lead  a  life  of  comparative  uselessness ;  in  those  who 
deliberately  select  the  radical  treatment  to  be  relieved  of  their 
symptoms;  and  in  cases  of  serious  nervous  and  physical  deteri- 
oration, the  consequence  of  the  pelvic  disease.  It  is  also  justifi- 
able for  the  relief  of  sterility  without  other  serious  symptoms. 
It  may  be  demanded  in  cases  of  acute  infection  with  persistent 
fever,  coincident  pelvic  abscesses,  and  other  symptoms  of  sepsis; 
to  anticipate  a  rupture  of  the  tube  into  the  bowel ;  by  fistuljE  into 
the  bowel  or  elsewhere  after  the  tube  has  been  perforated;  by 
evidences  of  tuberculous  infection  of  the  tube  or  by  symptoms 
justifying  the  suspicion  of  mahgnancy.  Acute  peritonitis  in  the 
course  of  a  salpingitis  may  be  an  urgent  indication  for  immediate 
operation.  It  is  plain,  therefore,  that  the  large  majority  of  the 
cases  of  salpingitis  are  only  amenable  to  or  actually  demand 
operative  treatment. 

The  operations  available  for  the  cure  of  salpingitis  are  sever- 
ance of  adhesions  and  reposition  of  the  tubes;  salpingostomy; 
salpingectomy,  partial  or  complete ;  salpingo-oophorectomy;  and 
hysterectomy  with  removal  of  the  tubes  and  ovaries.  The  tubes 
may  be  approached  for  any  of  the  operations  required  by  the 
vaginal  or  by  the  abdominal  route. 

It  is  always  impossible  to  determine  beforehand  which  one 
of  the  operations  just  detailed  is  necessary  for  the  patient's 
symptomatic  cure.  The  surgeon  should  only  undertake  such 
an  operation  with  full  permission,  before  witnesses  or  in  writing, 
to  do  whatever  in  his  judgment  might  be  necessary,  but  with  the 
understanding  that  all  structures  and  organs  should  be  spared 
that  might  be  left  behind  without  compromising  the  woman's 
health  in  the  future  or  jeopardizing  her  immediate  recovery. 

The  choice  of  the  vaginal  or  abdominal  route  should  be  gov- 
erned by  the  following  considerations:  If  the  inflammation  is  in 
an  acute  infectious  stage  with  fever,  the  vaginal  route  is  the 
safer.     If  the  woman  is  profoundly  reduced  by  cachexia  or  septic 


Treatment  of  Tubal  Inflammation  421 

intoxication  and  the  loss  of  nervous  strength  seen  occasionally 
in  chronic  cases,  especially  with  large  accumulations  of  pus  in 
the  tubes,  the  vaginal  operation  shocks  her  less  and  has  a  lower 
mortality.  If  the  abdomen  is  very  fat,  if  the  vagina  is  very  ca- 
pacious and  plastic  operations  are  to  be  performed  coincidentally 
on  its  walls,  if  the  woman  is  advanced  in  years,  the  vaginal  route 
may  be  preferable.  But  the  operative  treatment  of  salpingitis  by 
colpotomy  has  grave  disadvantages.  The  operation  must  often 
be  more  radical  than  it  need  be ;  it  is  safer  and  easier,  as  a  rule, 
to  remove  the  uterus  and  its  appendages  by  the  vagina  for  sal- 
pingitis than  to  do  a  more  conservative  operation.  During  the 
furor  for  this  operation,  originating  in  France  with  Doyen,  in 
Germany  with  Landau,  and  spreading  over  the  civilized  world, 
thousands  of  uteri,  tubes,  and  ovaries  have  been  needlessly 
sacnficed.  It  is  impossible  to  examine  the  abdominal  contents 
satisfactorily  in  a  vaginal  section,  especially  the  appendix ;  hence 
the  operation,  while  often  too  radical  in  one  sense,  is  insufficient 
in  another.  There  is  much  greater  danger  of  injury  to  the  in- 
testines in  a  vaginal  than  in  an  abdominal  section.  In  290  radi- 
cal vaginal  operations  for  salpingitis  by  Landau,  Terrier,  and 
Hartmann,  the  bowel  was  injured  27  times,  or  in  almost  10  per 
cent,  of  the  operations.^  There  is  a  greater  danger  of  primary 
and  secondary  hemorrhage  than  in  abdominal  section.  The 
latter  is  more  likely  to  occur  from  injury  to  the  uterine  artery 
in  an  attempted  consei-vative  operation  by  the  vagina.  The 
former  may  necessitate  the  relinquishment  of  the  vaginal  opera- 
tion and  a  hurried  abdominal  section.  There  is  a  greater  danger 
of  obstruction  of  the  bowels  after  a  vaginal  section,  especially 
if  clamps  are  used  to  close  the  vessels  in  the  broad  ligaments  ; 
there  is  likewise  greater  danger  of  injury  to  the  ureters.  For 
these  reasons  the  abdominal  is  to  be  preferred  to  the  vaginal  sec- 
tion except  in  the  limited  number  of  cases  already  enumerated  in 
which  for  special  reasons  the  vaginal  operation  is  the  safer  of 
the  two. 

SeveraJice  of  Adhesions  from  Perisalpingitis  and  Reposition  of 
Displaced  Tubes  by  the  Abdomijial  Rotite. — The  tubes  themselves 
may  not  be  structurally  diseased  nor  occluded,  but  are  displaced 
downward  and  backward  and  are  adherent  to  the  bowel  or  to 
the  posterior  surface  of  the  broad  ligaments,  dragging  the  uterus 
backward  and  preventing  a  reposition  o-f  the  retroverted  uterus. 
A  vaginal  section  and  the  separation  of  the  adhesions  around  the 
tubes  through  the  anterior  or  posterior  vaginal  vault  is  easily 
accomplished  and  sounds  plausible,  but  it  is  difficult  to  prevent 
the  tubes  from  returning  to  their  original  position  and  becoming 

^   Mainzer,  "Arch.  f.  Gyn.,"  Bd.  xliv,  p.  421. 


42  2  The  Fallopian  Tubes 

adherent  again.  The  adhesions  can  be  more  safely,  thoroughly, 
and  satisfactorily  freed  by  the  finger-tip  or  by  a  blunt  dissection 
through  the  abdominal  incision,  and  it  is  always  possible  to  restore 
and  to  retain  them  in  a  normal  position  removed  from  the  raw 
surfaces  from  which  they  have  been  freed,  either  by  suspending 
the  uterus  to  the  abdominal  wall  or  by  suspending  the  infundibulo- 
pelvic  ligaments  (the  suspensory  ligaments  of  the  ovaries)  to  the 
iliac  fascia  as  is  done  in  the  operation  for  prolapsus  ovarii  (page 

450- 

Salpmgostoniy  after  Abdominal  Section. — An  incision  may  be 

made  in  the  tube  to  restore  its  patency  if  the  abdominal  ostium 
is  closed,  if  there  are  but  moderate  distention  of  the  ampulla,  a 
fairly  healthy  condition  of  the  tubal  mucosa,  and  no  serious  in- 
filtrations of  its  walls.  A  linear  incision  may  be  made  over  the 
top  of  the  tube  as  near  as  possible  to  the  abdominal  extremity, 
trusting  to  the  circular  fibers  on  the  tubal  wall  to  keep  the  wound 
gaping.  There  is  greater  certainty  of  success,  however,  in  ex- 
cisinsf  a  "window"  in  the  tube-wall,  uniting  the  mucous  mem- 
brane  to  the  peritoneum  by  interrupted  sutures  of  fine  catgut. 
It  has  been  proposed  to  sew  the  ovary  into  the  opening  thus 
made  (Gersuny).  The  object  of  this  operation  is  to  cure  ster- 
ility. The  prospect  of  success  is  not  brilliant.  In  77  operations 
by  Gersuny,  Martin,  and  Mackenrodt,  conception  followed  in  5 
instances  1  (6.5  per  cent.). 

Salpingectomy  by  the  Abdominal  Route. — The  removal  of  the 
tube  is  indicated  if  its  walls  or  interior  are  so  badly  diseased  that 
there  is  no  hope  of  a  restitution  to  the  normal ;  if  there  is  no 
likelihood  of  symptomatic  cure  with  the  tube  remaining  ;  if  it  is 
the  site  of  an  acute  infectious  process  that  is  Hkely  to  spread  or 
develop  into  a  pyosalpinx,  as  in  acute  gonorrhea  or  strep- 
tococcic infection  ;  if  there  is  reason  to  suspect  tuberculosis  or 
malignancy.  There  are  several  different  forms  of  salpingectomy. 
The  excision  of  the  tube  may  be  only  partial ;  the  inner  third 
may  be  comparatively  healthy  even  with  extensive  and  long- 
continued  disease  of  the  ampulla,  and  may  be  left  behind — 
partial  salpingectomy.  It  is  often  necessary .  to  remove  the 
ovary  with  the  tube — salpingo-oophorectomy.  The  tube  may 
be  completely  removed  by  excising  a  wedge-shaped  piece  from 
the  uterine  cornu  whence  it  emerges — complete  salpingectomy. 
A  stump  of  the  tube  may  be  left  on  the  uterine  cornu — sal- 
pingectomy. 

The  nature  of  the  operation  required  can  only  be  determined 
after  the  abdomen  is  opened.  In  addition  to  the  physical  con- 
ditions exposed  to  sight  and  touch,  the  patient's  age,  social 
1  Veit,  "  Handbuch  der  Gyii.,"  vol.  3-,  p.  803. 


Treatment  of  Tubal  Inflammation  423 

condition,  and  circumstances  must  be  taken  into  account.  In  a 
woman  approaching  the  menopause  the  cessation  of  menstrua- 
tion and  an  enforced  steriHty  are  matters  of  no  moment.  No 
risks  should  be  taken  of  continued  or  recurrent  disease  in  struc- 
tures left  behind.  Even  in  women  of  child-bearing  age  special 
conditions  may  make  a  premature  menopause  and  sterility  rather 
desirable  than  otherwise.  The  nature  of  the  disease,  as  for  ex- 
ample tuberculosis,  may  demand  the  complete  removal  of  the 
tubes.  The  participation  of  the  w^iole  length  of  the  tube  in  a 
diseased  process  may  preclude  the  possibility  of  leaving  any 
portion  of  it.  An  associated  disease  of  the  uterus  or  of  the 
parametrium  may  indicate  not  only  salpingectomy,  but  hysterec- 
tomy as  well. 

But,  in  general,  an  effort  should  be  made  to  preserve  all  the 
structures  that  may  be  left  without  danger  to  the  patient's  life 
and  health,  to  make  conception  possible  in  the  future,  and  to  in- 
sure the  continuance  of  menstruation. 

In  acute  salpingitis,  gonorrheal  or  streptococcic,  without  in- 
volvement of  the  ovaries,  with  dark  red,  soft,  swollen  tubes,  the 
serosa  flaked  with  lymph,  perhaps,  and  drops  of  pus  oozing 
from  the  abdominal  ostia,  the  best  immediate  and  future  results 
are  secured  by  complete  salpingectomy  without  removal  of  the 
ovaries.  The  patient's  acute  symptoms  of  violent  pain  and  fever 
disappear ;  she  is  saved  from  the  risk  of  pelvic  or  general  per- 
itonitis ;  there  is  no  danger  of  the  development  of  pus-tubes  in 
the  future,  or  of  recurrent  infections  of  the  tubes,  and  she  men- 
struates normally.  In  streptococcic  infection  the  tubal  disease 
may  be  unilateral ;  in  gonorrhea  it  is  likely  to  be  bilateral.  In 
the  latter  case  the  woman  is  rendered  sterile  by  the  complete 
bilateral  salpingectomy,  but  no  more  so  than  she  would  be  by 
double  pus-tubes. 

It  is  often  possible  to  leave  the  inner  third  of  one  or  both  tubes 
and  one  or  both  ov^aries.  Even  if  only  the  inner  third  of  one  tube 
and  the  ovary  on  the  other  side  remain,  the  woman  is  in  better 
condition  than  if  she  were  rendered  necessarily  sterile  by  double 
salpingo-oophorectomy.  She  is  at  least  sustained  by  the  hope  of 
maternity,  and  is  saved  from  the  pitiable  melancholia  often  seen  in 
the  woman  intensely  desirous  of  offspring,  but  conscious  that  she 
is  doomed  to  a  childless  existence.  Some  risk  is  run  by  this  course 
of  a  persistence  of  symptoms  or  of  an  inflammation  subsequently 
dev^eloped  in  the  structures  remaining,  but  the  author  is  convinced 
by  a  long  experience  covering  the  period  when  no  attempt  was 
made  to  conserve  any  of  the  pelvic  organs  and  the  later  time  when 
the  advantages  of  conservative  surgery  have  been  recognized  that 
the  latter  course  is  the  only  one  justifiable. 


424  The  Fallopian  Tubes 

A  consideration  governing  the  choice  of  the  way  in  which  a 
tube  shall  be  removed  is  the  comparative  ease  and  rapidity  of  the 
different  methods.  The  quickest,  and  easiest,  and  most  certain 
operation  for  the  control  of  the  blood-vessels  and  the  amputation 
of  a  tube  is  to  ligate  the  broad  ligament  en  masse  with  a  double 
ligature^  and  to  cut  off  the  tube,  ovary,  and  mesosalpinx  above 
the  ligature.  In  a  case  necessitating  a  rapid  operation,  or  if  there 
are  technical  difficulties  making  the  other  procedures  embarrassing 
to  the  operator,  a  salpingo-oophorectomy  may  be  performed  which 
could  otherwise  be  avoided.  On  the  contrary,  one  of  the  other 
methods  of  salpingectomy  may  be  forced  upon  the  operator  by 
the  physical  conditions  in  the  tube  or  broad  ligament.  In  strepto- 
coccic infection  there  is  often  an  extraordinary  thickening  of  the 
mesosalpinx  so  that  a  mass  ligature  anywhere  is  out  of  the  ques- 
tion ;  the  blood-vessels  must  be  tied  separately  and  the  tube 
excised  entire  by  cutting  it  loose  from  the  broad  ligament  and  by 
a  wedge-shaped  excision  of  the  uterine  cornu.  As  the  blood- 
vessels are  cut  they  are  clamped  with  hemostats  and  afterward 
ligated.  Again  the  tube  may  be  diseased  in  its  whole  length; 
its  walls  as  they  leave  the  uterus  may  be  infiltrated  or  so  necrotic 
that  a  ligature  cuts  through  them.  In  such  a  case  a  complete 
salpingectomy  is  indicated.  In  case  it  is  equally  easy  to  resort  to 
any  method,  and  if  the  whole  tube  should  be  removed,  the  mass 
ligature  of  the  broad  ligament  had  better  be  avoided,  though  it 
is  not  such  a  disadvantageous  method  as  a  younger  generation 
which  lacks  experience  with  it  would  have  us  believe.  (See  page 
618.) 

In  any  case  in  which  the  removal  of  the  tubes  is  indi- 
cated the  ovaries  should  not  be  removed  simply  because  the 
tubes  are.  They  should  be  treated  on  their  own  merits.  If  they 
are  comparatively  healthy  and  do  not  promise  to  be  a  source 
of  pain  and  discomfort  in  the  future,  they  should  not  be  dis- 
turbed. It  is  quite  as  easy,  if  not  easier,  to  remove  the  tubes 
without  as  with  the  ovaries.  In  the  former  case  the  ligature  on 
the  outer  edge  of  the  broad  ligament  is  placed  between  the  tube 
and  the  ovary,  taking  in  about  a  third  of  the  broad  ligament  and 
including  the  ovarian  fimbria.  The  incision  which  frees  the  tube 
is  made  in  the  mesosalpinx  above  the  ovary. 

Hysterectomy  coincident  with  the  removal  of  diseased  tubes 
should  also  be  performed  only  for  distinct  disease  or  abnor- 
mality of  the  uterus.  The  argument  that  a  uterus  without  tubes 
or  ovaries  is  a  superfluous  organ  is  fallacious.  The  uterus  contrib- 
utes to  the  strength  of  the  vaginal  vault.  Its  removal  leads  to 
shortening   and   contraction   of  the  vagina.      Even  if  the  cervix 

^  For  the  detailed  technic  of  salpingectomy  see  page  618. 


Treatment  of  Tubal  Inflammation  425 

alone  is  left,  the  vagina  and  its  \ault  are  more  normal  than  if  the 
vaginal  vault  ended  in  a  blind  pouch  closed  b\'  cicatricial  tissue. 
Hysterectomy  should  only  be  performed  coincidently  with  the 
removal  of  diseased  tubes  if  the  m}'ometrium  is  the  seat  of 
infection  or  chronic  disease  threatening  the  individual's  future 
health,  or  if  the  endometrium  is  tuberculous  or  the  site  of  a 
malignant  growth.  Hyperplastic  interstitial  endometritis  is  not  a 
sufficient  indication,  nor  is  chronic  gonorrheal  endometritis.  The 
former  may  be  cured  by  a  curettage,  which  should  precede 
almost  every  operation  for  salpingitis  ;  the  latter  may  be  cured 
by  a  curettage  and,  if  necessary,  a  high  amputation  of  the 
cervix,  for  the  cervical  glands  are  the  source  of  the  intractable 
uterine  leukorrhea  resulting  from  gonococcic  infection.  Vaginal 
section,  as  already  stated,  has  a  distinct  field  of  usefulness  in 
salpingitis.  It  is  most  valuable  in  acute  infectious  inflammation 
with  a  large  accumulation  of  pus  in  the  tubes  or  in  the  profound 
cachexia  occasionally  seen  with  large  pus-tubes.  An  incision 
through  the  posterior  vaginal  vault  around  the  cervix  into  Doug- 
las's pouch,  enlarged  by  a  linear  incision  of  the  vaginal  vault  in 
the  median  line,  enables  one  to  pull  the  distended  tubes  one 
after  the  other  into  the  vagina,  incise  them,  wash  out  the  pus 
through  a  two-way  catheter,  and  to  pack  each  tubal  canal  with  a 
strip  of  gauze.  Douglas's  pouch  is  also  packed  with  gauze.  At 
the  end  of  forty-eight  hours  the  gauze  may  be  removed ;  if 
necessary,  under  temporary  anesthesia,  the  tubes  are  again  irri- 
gated and  Douglas's  pouch  is  again  packed.  The  dressing  is 
renewed  every  second  day  until  all  discharge  ceases.  A  complete 
symptomatic  cure  may  be  obtained  in  this  way  and  nothing  more 
is  required.  The  tubes  are  closed  permanently  by  granulation 
tissue  in  their  interior.  Otherwise  the  woman  is  normal  and  a 
careful  pelvic  examination  reveals  little  trace  of  her  former 
serious  disease.  ^  At  the  worst,  the  infectious  stage  of  the  in- 
flammation has  subsided  and  a  subsequent  abdominal  section 
for  the  removal  or  other  treatment  of  the  adherent  chronically 
inflamed  tubes  is  comparatively  safe. 

It  is  perfectly  possible  to  remove  one  or  both  tubes  with  or 
without  the  ovaries,  or  the  uterus  and  its  adnexa  for  pelvic  in- 
flammation by  the  vagina,  and  there  are  cases  already  enumer- 
ated in  which  this  form  of  operation  is  preferable  ;  but  except  in 
the  infrequent  instances  presenting  distinct  indications  for  a  vaginal 
operation,  abdominal  section  for  salpingitis  is  the  more  satis- 
factor}^,  the  safer,  and  the  better  operation.  (For  the  technic 
of  vaginal  section  see  page  640.) 

iThe  author  has  examined  women  years  after  this  treatment,  finding  a  surpris- 
ingly good  pelvic  condition  and  a  negative  history  of  pelvic  pain  or  discomfort. 


426  Extra-uterine  Pregnancy 


EXTRA-UTERINE  PREGNANCY. 
By  extra-uterine  or  ectopic  pregnancy  is  meant  the  develop- 
ment of  an  impregnated  ovum  outside  of  the  uterine  cavity.  The 
condition  was  described  by  Riolanus,  Benedict  Vassal  (1669),  and 
by  Regnier  de  Graaf.  Abdominal  sections  for  extra-uterine 
pregnancies  were  performed  by  Nufer  (1500)  and  by  Dirlewang 
(1549).  Bohmer  (1752)  differentiated  the  tubal,  ovarian,  and 
abdominal  forms  of  ectopic  gestation.  Schmidt  (1801)  described 
interstitial  pregnancy. 

Frequency. — The  exact  proportion  of  extra-uterine  to  intra- 
uterine gestations  is  difficult  to  determine.  It  is  said  to  be  about 
I  to  500.  Winckel,  however,  saw  but  16  cases  in  22,000  births, 
and  Bandl,  in  Vienna,  but  3  out  of  60,000.  In  the  larger  cities  of 
America  a  considerable  number  occur  annually.  I  have  ope- 
rated on  13  patients  for  extra-uterine  pregnancy  in  nine  months. 
Classification  Based  upon  the  Situation  of  the  Develop= 
ing  Ovum  : 
Tubal. 

Tubo-uterine,  or   interstitial.      The   ovum    develops  in  that 

portion  of  the  tube  within  the  uterine  wall. 
Tubal  proper. 

Tubo-ovarian.        The    ovum    is    attached    to    the     ovarian 
fimbria. 
■Ovarian.     The  ovum  develops  in  a  Graafian  follicle. 
Abdominal.      In    primary    abdominal     pregnancy    the    ovum 
attaches    itself  to  the  peritoneal  investment   of  the   uterus, 
the  broad  ligament,  or  the  intestines. 
Secondary  Abdominal. 

Ovario-abdominal.      The  ovum,  beginning  its  growth  in  the 

ovary,  pushes  its  way  out  into  the  abdominal  cavity. 
Tubo-abdominal.  The  ovum,  at  first  contained  in  the  tube, 
escapes  into  the  abdominal  cavity  by  rupture,  by  a 
gradual  separation  of  the  fibers  in  the  tubal  coat,  or  by 
extrusion  through  the  abdominal  ostium.  There  is  a  form 
of  tubal  pregnancy  often  called  secondary  abdominal  or 
tubo-abdominal,  in  which  the  ovum  grows  downward 
and  backward  behind  the  peritoneum.  This  should  be 
known  as  a  broad-ligament  or  retroperitoneal  pregnancy. 
Utero-abdominal.  The  ovum  grows  at  first  in  the  uterine 
cavity,  but,  in  consequence  of  a  spontaneous  rupture  or 
separation  of  an  old  scar  in  the  uterine  wall,  becomes  an 
abdominal  pregnancy,  retaining  its  connection  with  the 
uterus  by  the  placenta. 
Etiology. — The   causes    of   ectopic    gestation    are     obscure. 


Changes  in   Uterus  and  Vagina  427 

Any  disease  of  the  mucous  membrane  of  the  tube  depriving  its 
cells  of  their  cilia,  forming  mucous  polyps,  or  otherwise  obstruct- 
ing its  caliber,  predisposes  to  an  arrest  of  the  impregnated  ovum  in 
its  passage  to  the  womb.  So  does  any  condition  interfering  with 
the  normal  peristalsis  of  the  tube.  Chronic  salpingitis,  therefore, 
is  often  found  associated  with  and  preceding  tubal  pregnane}'. 

Peritoneal  adhesions  constricting  or  distorting  the  tubes  and 
congenital  narrowness  of  their  caliber  may  also  obstruct  the 
tubal  canals.  A  diverticulum  in  the  tube,  an  accessory  tubal 
canal,  accessory  abdominal  ostia,  and  atresia  of  the  tube  have 
been  noted  in  connection  with  ectopic  gestation.  An  exaggera- 
tion of  the  serpentine  course  characteristic  of  the  tube  may  make 
the  progress  of  the  ovum  difficult  and  may  arrest  it  before  it  can 
reach  the  uterus.  Anything  which  increases  the  size  of  the  ovum 
before  it  has  emerged  from  the  tube  may  be  a  cause  of  extra- 
uterine pregnancy ;  thus,  external  transmigration,  twins,  or  an 
unusually  long  tube  may  result  in  such  an  abnormal  growth  of 
the  ovum  before  its  arrival  in  the  uterine  cavity  that  its  progress 
is  arrested  and  it  is  fixed  in  the  tube.  The  ability  of  the  ovum 
to  embed  itself  in  mucous  membrane  and  in  subjacent  tissue 
must  also  be  considered  in  accounting  for  a  tubal  pregnancy. 

Clinical  History. — In  each  of  the  situations  noted  above  the 
course  of  gestation  may  be  somewhat  different,  and  each  may 
present  an  individual  clinical  picture  on  account  of  the  difference 
in  the  surrounding  anatomical  structures.  The  general  presump- 
tive signs  of  pregnancy  are  commonly  the  same  as  in  intra-uterine 
gestation,  but  there  is  usually  severe  pain.  Extra-uterine  preg- 
nancy occurs  oftenest  between  the  twentieth  and  thirtieth  years. 
The  youngest  woman  affected  was  fourteen,  the  oldest  forty-seven 
years  of  age. 

Changes  in  Uterus  and  Vagina. —  In  all  the  forms  these 
changes  are  alike.  Most  of  the  alterations  characteristic  of  intra- 
uterine pregnancy  are  found  :  hypertrophy  of  the  vaginal  mucous 
membrane,  with  increased  blood-supply  (purple  tinge)  and  in- 
creased secretion  ;  a  soft  cervix  and  a  patulous  os  ;  an  enlarged 
uterus,  and,  in  the  majority  of  cases,  a  development  of  a  decidu- 
ous membrane,  undergoing  the  same  change  as  in  intra-uterine 
gestation  preparatory  to  its  separation  and  extrusion,  which 
occurs  in  extra-uterine  gestation  usually  between  the  eighth  and 
twelfth  week,  the  membrane  being  expelled  as  a  complete  cast  of 
the  uterus  and  even  of  the  tubes,  or  in  shreds.  The  usual  clini- 
cal history  of  ectopic  gestation  is  absence  of  menstruation  until 
the  death  of  the  embryo  or  rupture  of  the  sac,  when  the  menses 
return  with  the  discharge  of  the  decidua.  The  metrorrhagia 
which  thus  begins  may  continue  for  a  long  time. 


Fig.   392. — Tubal  pregnancy,  unruptured. 


Fig.   393. — Ruptured   tubal    pregnancy  and  extrusion   of   embryo,    contained  in   its. 

amnion. 
428 


Clinical   History  and  Pathology  429 

The  other  changes  in  the  maternal  organism  may  vary  with 
the  situation  of  the  developing  ovum. 

Clinical    History   and    Pathology   of    Tubal    Pregnancy. — 

Usually  the  woman  has  had  children,  but  a  long  time  has  elapsed 
since  the  birth  of  the  last  child.  The  most  frequent  situation  of 
an  extra-uterine  gestation  is  the  outer  third  of  the  tube  (the  am- 
pulla^). In  this  position  it  may  grow  upward  into  the  abdominal 
cavity,  distending  the  tube-walls  to  the  point  of  rupture,  or  it  may 
grow  downward  between  the  layers  of  the  broad  ligament,  and 
then  backward  and  upward  behind  the  posterior  parietal  layer  of 
the  peritoneum  (broad-ligament  gestation).  The  tubal  walls 
grow  thicker  from  the  development  of  their  muscle-fibers,  except 
at  spots,  especially  on  the  upper  and  posterior  surfaces,  where 
rupture  may  occur,  the  woman  experiencing  severe  cramp-like 
pain,  followed  by  symptoms 

of  profound  shock  and  death  ,  J^-- 

from    hemorrhage,  in  a  few  ^r^-":-: 

hours.      Fever  is  often  seen,  i^Wj?<-       ■\\ 

sometimes     to    a    hio-h    de-  ~  ■"  -^  .^ 

gree,    even     before    rupture       ,,  ■,     ^_  ,. 

occurs.     The  usual  tempera-  ^   / 

ture,  however,  before  rupture 
is  between  99°  and  100°  F. 
Exceptionally  the  tubal  ges- 
tation may  proceed  to  full 
term  (6  per  cent,  of  tubal 
pregnancies — Winckel).  In 
these  cases  the  ovule  has 
probably  at  first  grown  down- 
ward and  backward.       If  rup-  Fig.    394.— Rupture.l  tubal  pregnancy. 

ture  occurs,  it   usually  takes 

place  between  the  eighth  and  twelfth  weeks,  but  it  may  be  seen 
as  early  as  the  fourteenth  day,  ^  or  after  the  sixth  month.  If 
the  tube  ruptures  upon  the  upper  or  posterior  aspect  of  the 
sac,  the  sac-contents  are  extruded  into  the  peritoneal  cavity 
with  an  intraperitoneal  hemorrhage.  If  rupture  occurs  on 
the  lower  aspect,  the  contents  of  the  ovum  and  the  blood  find 
their  way  between  the  layers  of  the  broad  ligament  and  the 
pelvic  fascia,  giving  rise  to  an  extraperitoneal  hematocele.  The 
first    variety    is  usually    fatal  ;  the   last    is    not    always   directl}' 

1  Martin's  statistics  of  55  cases  of  extra-uterine  pregnancy  give  this  situation 
in  49. 

2  Ross,  "  Amer.  Jour.  Obstet,"  October,  1895.  According  to  Hecker's  statistics 
of  45  cases,  rupture  occurred  26  times  in  the  first  two  months,  n  times  in  the  third, 
7  in  the  fourth,  and  once  in  the  fifth.  In  2  of  my  cases  rupture  occurred  no  later  than 
the  fourteenth  day. 


430 


Extra-uterine  Pregnancy 


dangerous  to  life,  but  the  layers  of  the  broad  ligament  may  rup- 
ture when  distended  with  blood,  and  the  bleeding  then  becomes 
intraperitoneal  and  unlimited.     The  bleeding  may  also  be  limited 


Fig.  395. — Ruptured  tubal  pregnancy  in  the  cornual  end  of  the  isthmus,  not 
further  advanced  than  fourteen  days.  Enormous  intra-abdominal  hemorrhage.  Cor- 
pus luteum  in  opposite  ovary.      Internal  transmigration  of  the  ovum? 


Fig.    396. — Ruptured  tubal  pregnancy. 


by  peritoneal  adhesions  shutting  off  the  peritoneal  cavity  and 
forming  a  closed  sac  in  the  iliac  region.  From  adhesions  to  in- 
testines, complications,  such  as  perforation  and  obstruction  of  the 
bowel,  may  occur. 


Clinical   History  and  Pathology 


431 


The  mucous  membrane  of  the  tube  undergoes  a  change,  being 
converted  into  a  decidua,  as  in  the  uterus,  but  there  are  in  the 
tube  connective-tissue  bundles  between  the  decidual  cells  ;  the 
layers  of  the  decidua  are  not  well  differentiated,  and  in  the  deepest 


Fig.   397. — Tube  and  four  months'  fetus.      Tube  injured  during  removal. 


layer  muscle-fibers,  connective-tissue  bundles,  and  decidual  cells 
are  intermingled.  ^  It  has  been  asserted  by  many  observers  that 
there  is  no  decidua  reflexa  in  the  tubal  pregnancies,  but  Winckel 

^  Kuhne  and  Kreisch  claim  that  there  is  no  decidua  formation  in  the  tubes  and 
that  the  cells  regarded  as  decidual  cells  are  cells  from  Langhans'  layer  of  the  chorion 
villi.  "Centralbl.  f.  Gyn.,"  No.  4,  1899,  and  "  Monatsschr.  f.  Geburtsh.  u.  Gyn.,'" 
Bd.  ix,  H.  6. 


432  Extra-uterine  Pregnancy 

has  demonstrated  it  twice.  The  pHcations  of  the  tubal  mucous 
membrane  are  unfolded  as  the  tube  expands. 

There  may  be  multiple  (twin  or  triplet^)  extra-uterine  ges- 
tation; coincident  intra- and  extra-uterine  pregnancy;  pregnancy 
first  in  one  tube  and  then  in  the  other  ;  simultaneous  pregnancies 
in  both  tubes;  ^  or  two  successive  pregnancies  in  the  same  tube. ^ 
H)-dramnios  was  noted  in  one  case  of  tubal  pregnancy  ^  and  a 
thoracopagus  was  found  in  another.^ 

Clinical  History  of  Interstitial  Pregnancy. — In  these  cases 
the  ovum  develops  in  the  uterine  wall,  the  inner  side  of  the 
sac  often  projecting  into  the  uterine  cavity,  and  having  on  its 
outer  side  the  round  ligament  and  the  whole  length  of  the  tube. 
The  usual  termination  of  this  kind  of  ectopic  gestation  is  rupture 
into  the  peritoneal  cavity.  Hecker  collected  twenty-six  cases,  all 
ending  in  rupture  before  the  sixth  month.  Rupture  into  the 
uterine  cavity  and  expulsion  of  the  fetus  through  the  cervix  are 
possible.  Rupture  into  or  growth  between  the  layers  of  the 
broad  ligament  is  also  possible. 

Clinical  History  of  Tubo=ovarian  Pregnancy. — The  ovum 
develops  between  the  fimbriae  of  the  tube  and  the  ovary.  The 
sac  may  rupture  with  the  usual  consequences  of  such  accident. 
It  is  possible,  however,  to  see  a  development  of  the  fetus  to  ma- 
turity. The  ovum  may  lodge  upon  the  ovarian  fimbria  and  may 
grow  inward  between  the  layers  of  the  broad  ligament. 

Clinical  History  of  Ovarian  Pregnancy. — The  ovum  im- 
pregnated while  it  is  still  within  the  Graafian  follicle  reaches 
some  degree  of  growth  and  development  within  the  ovary.  The 
condition  is  exceedingly  rare,  but  there  are  a  few  indubitable 
cases  on  record.  ^  One  case  in  Philadelphia,  reported  by  Dr. 
Baer,  went  to  term.  Miiller  and  Widerstein  have  reported  cases  of 
the  prolapse  of  a  pregnant  ovary  into  the  inguinal  ring  and  canal. 

1  Sanger,  "  Centralbl.  f.  Gyn.,"  No.  7,  1893.  Krusen,  "Tr.  Phila.  Co.  Med. 
Soc,"  Oct.,  1901. 

2  Alartin  has  collected  8  cases.   "Zeitschr.  f.  Geburtsh.  u.  Gyn.,"  Bd.  xxxviii,  H.  i. 

3  Coe,  "  N.  Y.  Med.  Record,"  May  27,  1893;  Borland,  "Repeated  Extra- 
uterine Pregnancy,"  "  Anier.  Jour.  Obstet.,"  April,  1898;  Royster,  "Combined 
Intra-  and  Extra-uterine  Pregnancy  at  Term,"  ibid.,  1897,  vol.  xxxvi,  p.  820; 
Mosely,  ibid.,  1896,  38  cases  of  extra-uterine  pregnancy.  Zinke,  ibid.,  xlv,  No.  5, 
1902,  88  cases.  Heinricius  and  Kolster  report  two  fully  developed  fetuses  in  one  tube, 
one  macerated,  the  other  well  preserved;    "Arch.  f.  Gyn.,"  Bd.  Iviii. 

*  "Arch.  f.  Gyn.,"  Bd.  xxii,  S.  57. 

5  "Centralbl.  f.  Gyn.,"  lf^94,  p.  232. 

^  Cases  are  reported  by  Potenko,  Werth,  Paltauf,  Leopold,  and  Martin.  See 
Winckel,  "  Geburtshiilfe"  ;  Kelly,  article  in  "American  Text-book  of  Obstetrics." 
Ludwig  ("Wiener  klin.  Wochenschr.,"  1896)  has  collected  18  cases  besides  I  of  his 
own.  Leopold  claims  that  there  are  13  authentic  cases  recorded  ;  "Arch.  f.  Gyn.," 
Bd.  lix.  Catharine  van  Tussenbraek  demonstrated  a  specimen  removed  by  Kouwer,  of 
Haarlem;  "Tr.  Ill  Congress  of  Gyn.  and  Obstet.,"  Amsterdam,  1899.  Indubitable 
cases  are  reported  by  Wathen  and  Franz  ("  Jahresbericht,"  1902,-vol.  xv,  p.  780). 


Terminations  of  Extra-uterine   Pregnancy        433 

Clinical  History  of  Abdominal  Pregnancy. — Primar\'  ab- 
dominal pregnane}-  is  exceedingly  rare.  Many  g\-necologists 
deny  its  occurrence,  but  there  have  been  a  few  authentic  cases. ^ 
The  conditions  in  the  free  abdominal  cavity  favor  the  progress  of 
pregnancy  to  the  mature  development  of  the  fetus.  The  peritoneum 
is  converted  into  a  decidua-like  membrane  wherever  the  ovum 
comes  in  contact  with  it,  and  from  this  source  the  chorion  and 
placenta  derive  nutriment.  The  ovum  is  surrounded  by  a  fibrous 
and  vascular  capsule.  In  abdominal  and  in  advanced  tubal  gesta- 
tion abortive  labor-pains  appear  at  term.  The  child  dies  at  or 
shortly  after  this  period,  and  the  liquor  amnii  is  absorbed  after  the 
death  of  the  fetus.  The  abdomen  is  consequently  reduced  in  size 
and  the  tumor  is  changed  in  consistency.  The  fetus  may  be  con- 
verted into  a  lithopedion  and  may  remain  as  an  innocuous  tumor 
in  the  abdomen  for  years.  The  child  is  likely  to  be  small 
and  ill-formed,  but  occasionally  overgrown  children  are  reported, 
no  doubt  on  account  of  a  prolongation  of  pregnancy.  In  advanced, 
cases  of  abdominal  pregnancy  the  fetal  movements  are  exceed- 
ingly painful  to  the  mother.  Abdominal  pregnancies  may  end  in 
rupture  of  the  sac  or  there  may  be  profuse  hemorrhage  into  the 
sac  cavity. 

Clinical  History  and  Pathology  of  Utero=abdominal  Preg= 
nancy. — This  condition  is  very  rare.  The  pregnancy  is  at  first 
intra-uterine,  but  the  ovum  escapes  into  the  abdominal  cavity 
through  an  opening  in  the  uterine  wall,  retaining  a  connection 
by  the  placenta  with  the  uterine  cavity.  The  process  of  extru- 
sion must  be  gradual.  These  cases  follow  either  a  Cesarean  sec- 
tion or  a  rupture  of  the  uterus  at  a  previous  labor.  The  fetus 
may  grow  to  full  term.  ^ 

Terminations  of  Extra=uterine  Pregnancy.  —  Death  and 
Absorption  of  the  Young  Euilvyo  zvith  Absorption  of  the  Liquor 
Amnii,  and  Atrophy  of  the  Gestatio?i  Cyst. — Of  all  the  termina- 
tions of  ectopic  gestation,  this  is  the  most  favorable.  It  is  ex- 
ceptional, and  should  never  be  counted  on  in  practice.  The 
embryo  must  die  before  the  second  month  to  be  completely  ab- 
sorbed. At  the  best  chronic  salpingitis  with  adhesions  persists, 
and  therefore  the  woman  may  be  left  a  chronic  invalid. 

^  Schlechtendahl  has  reported  a  case  of  primary  abdominal  pregnancy  in  which  a 
fetus  15  centimeters  long  was  found  encapsulated  near  the  spleen.  The  tubes  and 
uterus  were  normal  ("  Frauenarzr,"  1S87,  ii,  pp.  81-86).  Braun's  and  Zweifel's 
cases  ("Arch.  f.  Gyn.,"  Bd.  xli,  PI.  i  und  2),  in  which  the  placenta  was  attached 
to  the  posterior  uterine  wall  and  to  the  sigmoid  flexure,  and  Koeberle's  case,  in  which 
impregnation  occurred  through  a  vagino-abdominal  fistula  after  hysterectomy,  were 
unquestionably  primary  abdominal  pregnancies. 

^  "  Ausgetragene  secundare  Abdominalschwangerschaft  nach  Ruptura  uteri,  im 
vierten  Monat,"  Leopold,    "Arch.    f.    Gyn.,"  lii,   2,   376.       Fullerton,    "Annals  of 
Gyn.,"  Oct.,  1891." 
28 


434  Extra-uterine  Pregnancy 

Rupture  of  the  sac  and  profuse  JiemorrJiage  occur  most  com- 
monly in  tubal  gestation,  when  the  growth  is  upward  toward  the 
abdominal  cavity.  The  rupture  may  occur  when  the  ovule  grows 
downward  between  the  layers  of  broad  ligament ;  also  in  tubo- 
uterine,  tubo-ovarian,  ovarian,  and  abdominal  pregnancies.  The 
accident  commonly  destroys  the  embryo,  which  may  escape 
into  the  abdominal  cavity.  Up  to  the  second  month  the  ex- 
truded embryo  may  be  absorbed.  Later,  it  may  be  found 
lodged  among  the  intestines,  perhaps  far  removed  from  the  pelvic 
organs  and  usually  surrounded  by  clotted  blood.  ^  The  hemor- 
rhage may  be  fatal  in  as  short  a  time  as  two  hours  ;  it  usually 
takes  from  eight  to  sixteen  hours,  however,  for  the  woman  to 
bleed  to  death.  The  hemorrhage  may  be  fatal  as  late  as  the 
second,  third,  or  fourth  day,  or  there  may  be  successive  hemor- 
rhages, perhaps  days  apart  until  the  patient  is  gradually  ex- 
hausted or  is  suddenly  destroyed  by  an  unusually  profuse  out- 
pour of  blood.  Surprisingly  small  tubal  gestation  sacs  may,  on 
rupture,  give  rise  to  fatal  hemorrhage.  The  determining  cause 
of  rupture  is  not  always  apparent.  It  may  occur  while  the  pa- 
tient is  lying  quietly  in  bed,  but  may  follow  the  straining  of  defe- 
cation or  urination,  coitus,  a  blow  upon  the  abdomen,  a  gyne- 
cological examination,  an  operation  like  curetment,  or  any  sudden 
physical  effort  or  mental  excitement.  The  rupture  may  be  due 
to  contraction  of  the  tube-walls,  to  menstrual  congestion,  or  to 
the  steady  growth  of  the  tumor.  Rupture  of  the  sac  or  of  a 
blood-vessel  in  its  wall,  with  profuse  hemorrhage,  has  occurred 
long  after  the  destruction  of  the  embryo  and  cessation  of  growth 
in  the  sac  (two  years  in  one  case). 

Rupture  of  sac  with  extrusion  of  its  contents,  and  interstitial 
hemorrhage  into  its  sac-iualls,  without  escape  of  blood  into  peri- 
toneal cavity  or  between  the  layers  of  broad  ligament,  was  the 
termination  of  one  case  of  tubal  gestation  under  my  observation. 
This  occurrence  might  be  followed  by  atrophy  of  the  ovum  and 
sac. 

Tubal  moles  are  frequently  seen  as  the  result  of  an  old  tubal 
pregnancy ;  the  ovum  is  infiltrated  and  surrounded  by  blood, 
clotted  and  often  organized.  The  tubal  walls  are  also  infiltrated 
with  blood  and  are  much  thickened.  The  whole  mass  consti- 
tutes a  solid  tumor  of  the  tube  in  which  the  embryo  may  not  be 
found,  and  atrophied  chorion  villi  in  small  numbers  are  only  dis- 
covered after  a  careful  microscopical  search. 

1  Burford  reports  an  extraordinary  case  in  which  the  tube  ruptured,  the  fetus  was 
extruded  through  the  rent,  the  cord  was  torn  across,  and  the  fetus  with  the  cord 
attached  was  found  in  the  abdominal  cavity  inclosed  in  an  adventitious  sac.  The 
placenta  remained  in  the  tube,  and  the  rent  in  the  latter,  through  which  the  fetus 
escaped,  had  healed.      "  Brit.  Gyn.  Jour.,"  1892. 


Terminations  of  Extra-uterine  Pregnancy       435 

Groivtli  of  the  Fetus  after  Third  Month;  Its  Death  at  or 
before  Maturity  and  the  Changes  that  Occur  Afterivard. — A  con- 
tinued development  of  the  fetus  in  the  later  months  of  pregnancy 
is  seen  most  often  in  abdominal  or  in  tubo-ovarian  pregnancies, 
though  it  is  possible  in  the  tubal  gestation  with  retroperitoneal 
growth  (broad-ligament  pregnancy).  The  fetus  after  death  may 
be  converted  into  a  lithopedion  or  may  be  mummified,  and  in 
these  conditions  may  remain  in  the  abdominal  cavity  indefinitely 
(in  Sappey's  case  fifty-six  years),  or  may  be  removed  by  operation 
through  the  abdomen,  vaginal  vault,  or  possibly  by  the  rectum. 
The  soft  parts  may  macerate  and  may  be  absorbed,  leaving  the 
bones,  which  remain  as  an  innocuous  abdominal  tumor  or  ulcerate 
into  the  bladder,  intestines,  or  through  the  anterior  abdominal 


Fig.   398. — Tubal  abortion  and  extruded  mole. 


wall.  Ulceration  into  the  bladder  is  a  particularly  unfortunate 
complication.  I  have  seen  an  old  lady  die  of  peritonitis  caused 
by  the  ulceration  of  a  parietal  bone  through  the  transverse  colon. 
Her  history  indicated  an  abdominal  pregnancy  having  its  origin 
many  years  before. 

The  fetal  body  may  putrefy  from  the  contiguity  of  the  intes- 
tines and  their  contained  micro-organisms  and  the  consequent 
access  of  bacteria  to  the  highly  putrescible  sac-contents.  In  the 
same  way  the  gestation  sac  is  converted  into  an  abscess. 

Terminations  of  Ovarian  Pregnajicy. — There  may  be  an  arrest 
in  the  development  of  the  ovum  at  an  early  period.  In  one  case 
the  small,  cystic,  ovarian  tumor  containing  the  fetal  bones  was  re- 
tained in  the  abdomen  for  years.  In  another  case  the  fetus  went 
on  to  full   development,  then  died,  and  was   removed  in  a  good 


436 


Extra-uterine  Pregnancy 


state  of  preservation  at  least  one  }'ear  later.  Rupture  of  the  sac 
and  profuse  hemorrhage  may  occur. 

In  tubo-uteriiic  or  interstitial  pregnancies  the  ovum  and  em- 
bryo may  be  discharged  into  the  uterine  cavity,  and  may  be  evac- 
uated by  the  vagina.  There  are  at  least  two  such  cases  well 
authenticated.  Rupture  of  the  sac  and  hemorrhage  into  the 
peritoneal  cavity  are,  however,  the  rule.  In  Maschka's  case  the 
head  of  the  fetus  passed  into  the  abdominal,  the  breech  into  the 
uterine,  cavity. 

In  cases  of  so-called  tubal  abortion  (so  named  by  Werth) 
there  is  an  internal  rupture  of  the  tubal  wall  or  of  its  connection 
with  the  ovum,  and  blood  is  poured  through  the  fimbriated  ex- 
tremity of  the  tube  into  the  abdominal  cavity.  The  blood-clots 
filling  the  pelvis  in  such  a  case  may  have  a  peculiar  sausage-like 


Pig.   399. — Tubal  abortion  and  extruded  mole. 


form  imparted  to  them  by  the  tubal  canal.  The  whole  ovum 
may  possibly  be  extruded  through  the  abdominal  orifice  of  the 
tube,  as  in  two  cases  of  the  author's  (Figs.  398,  399),  and  in  one 
■case  in  which  the  fimbriated  extremity  was  closed  by  inflammator\' 
adhesions  the  outer  end  of  the  tube  was  converted  into  a  hema- 
toma. Kiistner  claims  that  tubal  abortion  is  much  more  frequent 
than  rupture.  In  75  cases  the  former  occurred  59,  the  latter  16, 
times.  ^  The  majority  of  the  cases  under  the  author's  observa- 
tion have  ended  by  tubal  abortion. 

It  is  possible  that  a  tubal  pregnancy  may  rupture  in  its  earl)' 
stages,  the  embryo  be  expelled  into  the  abdominal  cavity,  retain- 
ing its  connection  with  the  tube  by  the  cord  and  placenta,  and  the 
fetus  thus   continue  to  further  or  to  full   development.      This  is 

1  "Volkmann's  Samml.  klin.  Vortrage,"  N.  F.,  Nos.  244,  245. 


Symptoms  of  Extra-uterine   Gestation  437 

called  a  secondary  or  tubo-abdomiiial  pregnancy.  ^  Rupture  in 
cases  apparently  of  this  character  may  not  have  occurred.  There 
may  have  been  a  retroperitoneal  growth  of  the  ovum  and  an 
enormous  dilatation  of  the  tubal  walls.  Tuholske  ^  reports  a 
case  in  which  the  ovum  was  extruded  from  the  abdominal  ostium, 
became  attached  to  the  diaphragm,  and  developed  between  the 
right  lobe  of  the  liver  and  the  right  kidney. 

Grozvth  and  development  of  the  placenta  after  fetal  death  has 
been  described,  but  has  not  yet  been  demonstrated  beyond  doubt. 
It  would  seem  impossible,  arguing  from  the  behavior  of  the  pla- 
centa in  iitero  after  fetal  death. 

Profuse  hemorrhage  into  tJie  gestation  sac,  formiiig  a  large 
hematoma,  occurred  in  one  case  under  my  observation. 

Hematoceles  and  hematomata  in  the  abdomen,  pelvis,  and  pelvic 
connective  tissue  in  one-third  or  more  of  the  cases  are  due  to  the 
hemorrhage  from  a  ruptured  gestation  sac.  The  blood  may  col- 
lect in  front  of  the  uterus  (ante-uterine  hematocele),  more  com- 
monly behind  the  uterus  (retro-uterine  hematocele),  may  be  en- 
capsulated in  the  neighborhood  of  either  broad  ligament,  or  may 
be  contained  in  the  pelvic  connective  tissue  on  either  side  of  the 
uterus.  These  accumulations  of  blood  may  suppurate,  and  may 
thus  prove  fatal.  They  may  be  evacuated  by  puncture  through 
the  abdomen  or  often  through  the  vaginal  vault.  If  not  too  large, 
they  are  absorbed. 

Symptoms  of  Extra=uterine  Gestation. — The  Subjective  Signs. 
— In  the  early  weeks  or  months  the  subjective  signs  of  ectopic 
pregnancy  may  be  indistinguishable  from  those  of  normal  intra- 
uterine gestation.  In  the  tubal  variety,  which  is  by  far  the  com- 
monest, there  maybe  no  indication  of  any  abnormality  until  rup- 
ture occurs.  In  the  vast  majority  of  cases,  however,  rupture  is 
preceded  by  severe  cramp-like  pains,  usually  in  one  or  the  other 
iliac  region,  often  accompanied  or  followed  by  the  discharge  of 
deciduous  membrane  and  by  metrorrhagia. 

The  pain  of  extra-uterine  pregnancy  is  its  most  distinctive 
symptom.  It  may  be  defined  as  a  pain  described  by  the  patient 
in  strongest  terms  ;  occurring  in  paroxysms,  with  intervals  free 
from  suffering  ;  appearing  at  any  time  from  a  {&\n  days  to  months 
after  a  normal  menstruation  ;  situated  often  in  one  groin,  though 
frequently  indefinitely  referred  to  the  lower  abdomen  ;  extending 
down  one  leg  or  up  to  the  epigastrium;  and  a  pain  so  severe  as 
to  occasion  profound  systemic  disturbance — syncope,  followed  by 

2  Lusk  has  collected  three  such  cases.  The  fetus  survived  the  rupture  of  the 
tube,  or  the  extrusion  may  have  been  gradual  by  a  separation  of  the  fibers  in  the 
tube- wall. 

2  "Am.  Gyn.  Jour.,"  Dec,  1901.  Abstr.  in  "  Jahresbericht  ii.  d.  Fortschr.  a. 
d.  Gebiet  d.  Gyn.  u.  Geb. ,"  1902,  p.  779. 


438  Extra-Uterine  Pregnan-cy 

nausea  and  vomiting,  a  cold  sweat,  hysterical  outbreaks,  complete 
disability,  and  every  appearance  of  excessive  shock.  The  tem- 
perature is  almost  always  slightly  elevated.  There  may  be  high 
fever,  and  the  general  health  may  be  much  impaired.  When  ad- 
vanced development  occurs,  as  in  abdominal  and  in  some  cases 
of  tubal  gestation,  no  symptoms  may  arise  until  the  time  for  labor 
has  passed,  when  pain  and  other  complications,  due  to  the  peculiar 
character  of  the  abdominal  tumor,  may  appear.  There  is  usually 
cessation  of  menstruation  for  one  or  two  periods  ;  then  a  return 
of  the  flow  as  an  irregular  bleeding,  which  may  last  for  months. 
In  some  cases  irregular  bleedings  begin  with  conception  and  last 
until  rupture  ;  there  is  no  cessation  of  menstruation.  In  others, 
one  period  is  slightly  delayed  ;  those  after  and  before  are  normal. 
Again,  the  delayed  period  may  be  unnatural  in  character.  In 
exceptional  cases  the  menstruation  occurs  at  the  normal  time,  but 
is  more  profuse  or  scantier  than  normal.  In  59  cases  upon  which 
I  have  operated  there  was  no  absence  of  menstruation  in  17  ;  a  ces- 
sation of  menstruation  varying  from  ten  to  ninety  days  in  42. 
There  was  metrorrhagia  lasting  from  two  to  one  hundred  and 
twenty  days  in  41  cases  ;  there  was  a  discharge  of  decidua  in  25 
cases. 

Other  symptoms  noted  have  been  irritable  bladder  or  dysuria; 
marked  constipation  or  even  obstruction  of  the  bowels  if  the  tumor 
is  on  the  left  side ;  edema  of  the  corresponding  limb  and  aching 
pain  in  it,  especially  at  the  groin  ;  or  numbness  and  loss  of  power. 
Pulsating  vessels  may  be  felt  in  the  vaginal  vault.  ^ 

Objective  Signs. — In  tubal  pregnancies  an  exquisitely  sensi- 
tive tumor  may  be  felt  to  one  side  of,  behind,  or  possibly  in  front 
of  the  uterus,  quite  firmly  fixed  after  the  third  or  fourth  week,  and 
doughy  in  consistence.  ^  The  uterus  is  much  smaller  than  would 
be  expected  from  the  duration  of  the  pregnancy.  After  the  third 
month  ballottement  may  possibly  be  practised  upon  the  tubal 
tumor.  The  uterus  is  usually  displaced  forward,  backward, 
or  to  the  side  opposite  the  tumor.  The  decidua  is  expelled 
from  the  uterus  in  a  large  proportion  of  cases  (42  per  cent,  of  my 
own).  If  the  discharged  membrane  can  be  obtained,  it  will  pre- 
sent, under  the  microscope,  unmistakable  characteristics  of  de- 
cidua. It  may  be  extruded  in  fragments  or  as  a  complete  cast 
of  the  uterus. 

1  Hofmeier  claims  that  the  pulsation  of  arteries  on  one  side  of  the  cervix  and  not 
upon  the  other  is  a  valuable  sign  of  extra-uterine  pregnancy  ;  and,  moreover,  that  it 
is  a  sign  of  life  in  the  ovum,  ceasing  when  the  embryo  dies  and  the  ovum  stops  growing. 

2  For  three  or  four  weeks  the  tubal  tumor  is  free  ;  quite  suddenly  it  sinks 
into  the  pelvis  from  its  increasing  weight,  and  wherever  it  conies  in  contact  with  the 
pelvic  peritoneum  the  latter  is  changed  into  a  decidua-like  structure  to  which  the 
tube-walls  adhere. 


Diagnosis  of  Extra-uterine  Pregnancy  439 

Symptoms  of  Interstitial  Pregnancy. — A  diagnosis  is  diffi- 
cult or  impossible.  The  uterus  enlarges  to  a  greater  degree  than 
in  any  other  variety  of  ectopic  gestation,  and  it  may  be  impossible 
to  determine  whether  or  not  it  is  symmetrically  enlarged.  The 
condition  is  recognized  after  an  abdominal  section,  upon  a  careful 
intra-uterine  exploration,  or  after  rupture  of  the  sac. 

Abdominal  pregnancy  may  be  recognized  when  the  ovum 
occupies  Douglas's  pouch,  as  the  fetal  parts  may  be  made  out 
with  startling  distinctness  through  the  posterior  vaginal  vault. 
A  sacculated  uterus,  however,  might  easily  be  mistaken  for  an 
abdominal  pregnancy. 

Diagnosis. — A  diagnosis  of  extra-uterine  pregnancy  can  usu- 
ally be  made  before  rupture.  In  spite,  however,  of  careful  atten- 
tion to  the  patient's  history  and  a  painstaking  physical  exami- 
nation by  an  expert,  a  diagnosis  before  rupture  is  sometimes 
impossible.  Usually  the  condition  is  not  recognized  in  general 
practice  until  rupture  has  occurred.  At  this  time  a  history  of 
early  pregnancy,  a  paroxysm  of  frightful  pain,  sudden  collapse, 
symptoms  of  internal  hemorrhage,  with  abdominal  distention,  and 
a  vaginal  examination  showing  a  pelvic  tumor  with  possibly  the 
physical  signs  of  effusion  into  peritoneal  cavity,  make  the  diag- 
nosis perfectly  clear,  and  indicate  an  immediate  celiotomy.  These 
symptoms  have  been  closely  simulated  by  rupture  of  a  varicose 
vein  in  the  broad  ligament,  by  rupture  of  an  ovarian  cyst  or 
torsion  of  its  pedicle,  by  acute  suppurative  salpingitis,  by  criminal 
abortion  followed  by  infection,  in  which  a  false  history  is  purposely 
given,  and  by  pelvic  tumors  coincident  with  intra-uterine  preg- 
nancy. But  as  all  these  conditions  demand  the  same  treatment,  a 
mistake  in  the  differential  diagnosis  between  them  is  of  no  conse- 
quence. If  the  cramp-like  pains  of  ectopic  gestation  lead  a  patient 
to  consult  a  physician ;  if  she  give  a  clear  history  of  impregnation ; 
if  she  present  all  the  earlier  signs  of  pregnancy,  with  the  discharge 
of  blood  and  membrane  which  the  microscope  shows  to  be  de- 
cidual ;  if  there  is  a  very  sensitive  tumor  in  the  neighborhood  of 
the  uterus  on  which  ballottement  may,  perhaps,  be  practised,  and 
if  the  uterus  is  not  so  large  as  it  should  be,  the  diagnosis  is  justi- 
fied, and  the  necessary  treatment,  also,  involving,  as  it  does,  a 
serious  operation.  Among  the  conditions  in  the  pelvis  that  may 
make  the  diagnosis  impossible  are  :  abortion,  in  consequence  of 
or  coincident  with  some  growth  near  the  uterus  ;  pyosalpinx, 
with  an  indistinct  or  untrustworthy  history  of  pregnancy ;  intra- 
uterine pregnancy,  with  rapid  development  of  a  fibroid  on  one 
side  of  the  uterus  ;  development  of  an  impregnated  ovule  in  one 
horn  of  a  bicornate  uterus,  or  on  one  side  of  a  double  uterus. 
A  common  error  constantly  occurring  in  general  practice  is  to 


440  Extra-uterine  Pregnancy 

mistake  an  extra-uterine  pregnancy  for  an  incomplete  abortion. 
I  find  in  my  notes  of  fifty-nine  cases  this  mistake  made  by  the 
attending  ph}'sician  in  twenty. 

Prognosis. — Without  surgical  treatment  about  two-thirds  of 
the  cases  die;  one-third  escape  the  immediate  danger  of  death. ^ 
Treated  by  abdominal  section,  the  mortality  should  be  about  5 
per  cent.,  or  lower  if  the  operator  sees  the  patient  in  time.  I 
have  performed  59  operations  with  three  deaths.  Two  of  the 
fatal  results  were  in  women  already  exsanguine,  who  died  a  few 
hours  after  the  operation  without  regaining  consciousness.  The 
other  was  in  a  chronic  drunkard,  who  died  on  the  fifth  day  from 
cirrhosis  of  the  liver.  Of  those  patients  who  do  not  die  directly 
in  consequence  of  the  tubal  gestation  a  large  proportion  remain 
invalids,  and  many  die  at  a  remote  period  from  various  complica- 
tions, as  bowel  obstruction,  ulceration,  suppuration,  or  hemor- 
rhage. 

Treatment. — As  soon  as  the  diagnosis  is  established  with 
reasonable  certainty,  whether  the  sac  has  ruptured  or  not,  the 
removal  of  the  gestation  sac  by  celiotomy  is  the  only  treatment 
worthy  of  consideration.  Electricity  is  an  uncertain  and  unre- 
liable remedy,  and  the  recoveries  ascribed  to  its  use  are  the  result 
of  nature's  effort  to  effect  a  cure.  Injections  into  and  puncture 
of  the  sac  to  destroy  the  embryo  should  be  relegated  to  the  cate- 
gory of  discarded  and  discredited  procedures. 

Abdominal  section  is  the  only  reliable  and  trustworthy  plan 
of  treatment.  The  removal  of  a  gestation  sac  and  the  control  of 
hemorrhage  is  sometimes  a  difficult  operation,  not  to  be  under- 
taken rashly  by  an  unskilled  operator.  In  favorable  cases  in  which 
a  trained  nurse  is  kept  in  constant  attendance,  and  in  which  the 
physician  can  reach  the  patient  quickly,  in  exceptional  cases  it 
might  be  justifiable  to  wait,  after  diagnosticating  extra-uterine 
pregnancy  before  rupture,  for  the  death  of  the  embryo  and  the 
atrophy  of  sac,  which  will  occur  in  about  one-third  of  the  cases. 
As  a  rule  of  practice,  however,  the  only  safe  plan  is  either  to 
operate  immediately  one's  self,  or  to  refer  the  patient  to  a  com- 
petent surgeon  without  delay. 

After  rupture,  the  patient's  only  hope  lies  in  an  immediate 
abdominal  section,   evacuation  of  the  blood  from  the  peritoneal 

1  In  265  cases  without  surgical  intervention,  36.9  percent,  recovered,  63.1  per 
cent,  died  (Winckel's  "  Geburtshiilfe,"  2.  Aufl.,  S.  254).  In  100  cases  collected  by 
Kivvisch,  the  mortality  was  82  per  cent.;  in  132  collected  by  Hecker,  42  per  cent.;  in 
130  by  Hennig,  88  per  cent.;  in  500  cases  collected  by  Parry  up  to  1876  the  mortality 
was  67.2  per  cent.;  in  626  cases  collected  by  .Schauta,  from  1876  to  1890,  241  ended 
spontaneously,  75  in  recovery,  and  166  in  death,  a  mortality  of  68.8  per  cent.  Martin 
states  that  of  585  cases  operated  upon,  76.6  per  cent,  recovered  ("  Centralbl.  f.  Gyn.," 
No.  39,  1892). 


Ireatment  of  Extra-uterine   Pregnancy  441 

cavit}',  the  lis^^ition  of  the  blood-vessels  supplying  the  sac,  and  its 
complete  removal. 

The  Tcchnic  of  Abdonwial  Section  for  Tubal  Pregnancy. — The 
operation  is  often  performed  in  an  emergency,  and  must,  there- 
fore, be  hurried.  Plenty  of  time,  however,  should  be  taken  to 
secure  an  absolutely  aseptic  condition  of  the  field  of  operation  in 
the  patient,  of  the  surgeon,  assistants,  dressings,  and  implements. 
If  possible,  the  patient  should  be  transported  to  a  well-appointed 
hospital.  If  there  has  been  much  bleeding  and  the  patient's  con- 
dition is  bad,  the  anesthesia  should  be  limited  and  the  operation 
should  be  finished  in  the  fewest  minutes  possible.  It  is  possible 
to  conclude  the  operation,  to  the  last  abdominal  stitch,  in  less 
than  eleven  minutes  and  with  less  than  an  ounce  of  ether.  ^  No 
attention  should  be  paid  to  the  blood  that  gushes  in  enormous 
quantities  from  the  abdominal  cavity  when  the  peritoneum  is  in- 
cised. It  has  already  been  shed  and  is  of  no  use  to  the  patient. 
The  side  affected  should  have  been  learned  by  the  history,  ^  if 
not  by  the  physical  signs.  This  tube  should  at  once  be  grasped 
between  the  thumb  and  fingers  of  one  hand,  the  broad  ligament 
should  be  transfixed  by  a  pedicle  needle  to  the  inner  side  of  the 
round  ligament,  and  ligated  en  masse, "^  with  three  turns  of  the 
silk  ligature,  one  to  each  side  of  the  pedicle  needle,  the  third 
around  the  whole  stump.  The  tube  and  ovary  are  then  cut 
away.  The  abdominal  cavity  should  next  be  flushed  with  a  large 
quantity  of  sterile  water."*  Drainage  is  rarely  necessary.  The 
author  has  not  drained  a  case  for  four  years  or  more,  though  for- 
merly he  drained  every  one.  If  drainage  is  deemed  necessary, 
the  abdomen  should  be  drained  with  both  a  glass  tube  and 
gauze  packing. 

For  twelve  or  twenty-four  hours  after  the  operation  vigorous 

^  A  patient  was  at  first  treated  by  her  physician  for  a  miscarriage — the  com- 
monest mistake  in  the  diagnosis  of  extra-uterine  pregnancy.  After  rupture  the  true 
condition  was  recognized,  but  the  woman  was  so  reduced  by  the  internal  hemorrhage 
that  she  was  pronounced  a  hopeless  case,  and  the  physician  left  the  house  late  at  night 
saying  he  would  call  the  next  morning  to  sign  her  death  certificate.  To  his  surprise 
he  found  her  alive.  A  few  hours  later  I  operated  on  her  with  success,  though  she  was 
pulseless  and  in  as  desperate  a  condition  as  possible. 

-  It  is  often  impossible  to  tell  from  a  physical  examination  which  tube  is  involved, 
but  I  have  found  the  history  of  pain  down  one  leg  and  not  the  other  of  great  value 
in  diagnosticating  the  side  affected. 

^  It  is  waste  of  invaluable  time  in  the  majority  of  cases  to  ligate  the  blood-vessels 
separately. 

*  I  have  practically  given  up  douching  the  abdominal  cavity  after  abdominal  sec- 
tions, except  in  extra-uterine  pregnancy.  There  is  no  other  means  which  so  rapidly 
and  surely  removes  blood-clots  from  the  abdomen.  It  is,  moreover,  a  great  advantage 
to  leave  the  large  quantity  of  hot  water  which  remains  in  the  abdominal  cavity  after 
irrigation.  Gallons  are  required  and  it  is  inconvenient  to  prepare  such  a  quantity 
of  normal  salt  solution.  There  is,  moreover,  no  great  advantage  in  the  use  of 
salt  solution. 


442  Extra-uterine  Pregnancy 

stimulation  and  an  active  treatment  for  the  acute  anemia  are 
necessary  if  there  has  been  a  profuse  hemorrhage.  Submammary 
or  intravenous  injections  of  normal  salt  solution  are  invaluable. 
If  drainage  is  employed,  the  glass  tube  is  sucked  out  by  a 
syringe  once  a  da\'  with  strictest  aseptic  precautions.  The 
gauze  is  removed  at  the  end  of  forty-eight  hours,  and  the  glass 
tube  is  then  withdrawn  after  a  rubber  tube  is  slipped  within  it  to 
take  its  place.  Through  the  rubber  tube  the  pelvic  cavity  is  irri- 
gated once  a  day  with  sterile  water.  The  irrigation  is  continued 
for  about  ten  days,  or  until  the  water  returns  perfectly  clear 
without  bringing  with  it  small  snowflake-like  clots  and  the  debris 
of  the  deciduous  formation  on  the  peritoneum  which  constitute 
the  adhesions  between  the  tubal  sac  and  surrounding  intraperi- 
toneal structures. 

The  vaginal  operation  for  tubal  pregnancy  in  the  first  three 
or  four  months  is,  as  yet,  in  its  infancy.  It  has  the  serious  dis- 
advantages that,  on  account  of  uncontrollable  hemorrhage,  a 
vaginal  hysterectomy  or  hasty  abdominal  section  may  be  neces- 
sary, and  if  the  tube  is  simply  incised  and  not  removed,  a  diseased 
and  useless  pelvic  organ  is  left  behind  to  be  a  source  of  future 
'trouble.  It  is  impossible  through  a  vaginal  incision  to  evacuate 
the  blood  and  blood-clots  lying  in  large  quantities  in  remote 
portions  of  the  abdominal  cavity.  Moreover,  as  in  all  vaginal 
sections,  nicety  and  precision  of  work  is  impossible  through  the 
vaginal  vaults. 

In  intostitial  pregnancy,  on  account  of  the  difficulty  of  diag- 
nosis, little  can  be  done  until  rupture  and  hemorrhage  have 
occurred,  when  an  abdominal  section  must  be  performed.  The 
sac  should  be  cleared  of  all  its  contents,  and  its  edges  should 
be  sewed  to  the  abdominal  wall ;  after  the  bleeding  vessels  are 
secured,  the  sac  should  be  drained.  If  this  technic  is  impossible, 
ligation  of  the  uterine  and  ovarian  arteries  is  indicated,  drainage 
of  the  sac,  or  possibly  supravaginal  amputation  of  the  uterus. 
It  might  be  well,  the  diagnosis  being  clearly  established,  to  try  to 
effect  evacuation  of  the  gestation  sac  into  the  uterine  cavity  after 
thorough  dilatation  of  the  cervical  canal.  A  mistaken  diagnosis, 
however,  would  lead  to  a  premature  termination  of  a  normal  intra- 
uterine pregnancy.  Tait  describes  a  case  in  which  he  found  it  pos- 
sible to  incise  the  sac,  turn  out  its  contents  and  drain  it,  after  fetal 
death.  ^  Engstrom  treated  a  case  successfully  by  incising  the  uter- 
ine wall,  extracting  the  dead  fetus  and  its  appendages,  making  and 
enlarging  an  opening  between  the  gestation  sac  and  the  uterine 
cavity,  sewing  the  uterine  wall  firmly  together,  as  after  a  Cesarean 
section,  and  closing  the  abdomen  without  drainage.  ^ 

1  London  "Lancet,"  1894,  I,  p.  38.  2  "  Centralbl.  f.  Gyn.,"  No.  5,  1896. 


Advanced  Extra-uterine   Pregnancy  443 

Ovarian  pregnancy  is  to  be  treated  as  a  tubal  pregnancy — 
namely,  by  excision  of  the  sac  with  the  ovary.  As  a  matter  of 
fact  the  operation  is  undertaken  in  these  rare  cases  for  an  ovarian 
tumor,  and  the  operator  discovers,  to  his  surprise,  after  opening 
the  abdomen,  the  contents  of  the  ovarian  cyst. 

/;/  advanced  extra-ntcrine  pregnancy  the  operator  should  delay 
interference  until  just  short  of  term,  or  until  the  beginning  of 
false  labor  pains,  when  the  fetus  and,  if  possible,  the  fetal  sac, 
should  be  enucleated  and  extracted  whole.  The  uterine  and 
Ovarian  arteries  are  previously  ligated.  It  is  not  infrequently 
necessary  to  cut  the  cord  off  short,  stitch  the  sac-wall  to  the 
abdominal  wall,  and  drain  the  sac.  Forty  operations  (1889- 
1896)  after  the  seventh  month  of  gestation,  with  living  and  viable 
infants,  have  been  collected  by  Dr.  R.  P.  Harris.  ^  In  this 
number  there  were  ten  maternal  deaths  ;  twenty-seven  infants 
survived  the  operation.  Von  Both  has  collected  83  cases  ;  in 
the  first  30  operations  there  were  25  deaths  ;  in  the  53  following, 
15;  and  in  the  last  8  operations,  only  i.^  Sittner  ^  has  col- 
lected 126  cases,  with  51  recoveries  and  10  deaths  since  1880. 
WJicn  deatli  of  tlie  fetus  has  occurred,  it  is  best  not  to  subject  the 
woman  to  the  danger  of  the  several  possible  ultimate  terminations, 
but  to  perform  celiotomy  and  to  remove  the  fetus  and  its  entire 
surrounding  sac.  If  the  exsection  of  the  sac  is  too  difficult  or 
dangerous,  it  is  permissible,  some  weeks  after  fetal  death,  to  cut 
the  cord  off  short,  leaving  behind  the  atrophied  remains  of  the 
placenta.  If  this  is  done,  the  sac-wall  should  be  stitched  to  the 
abdominal  wall,  and  thus  drained  for  a  length  of  time  until  the 
placenta  comes  away.  Meanwhile  daily  irrigations  are  required 
and  antiseptic  powders  may  be  dusted  in  the  sac-cavity.  In  case 
the  gestation  sac  is  low  down  in  Douglas's  pouch,  bulging  the 
posterior  vaginal  wall,  vaginal  section,  and  the  delivery  of  the  fetus 
by  the  natural  passage  may  be  considered  ;  but  the  dangers  and 
disadvantages  of  the  vaginal  operation  should  be  carefully  weighed. 
These  are  :  difficulty  of  extracting  the  fetus,  if  it  is  large  ;  uncon- 
trollable hemorrhage,  puncture  of  an  intestine,  infection  of  the 
general  peritoneal  cavity,  either  at  the  time  of  the  operation  or  in 
subsequent  irrigations  of  the  sac ;  and  adhesions  involving  the 
uterus  and  appendages  after  the  woman's  recovery  from  the 
operation.'*  Vaginal  section  is  preferable  in  case  of  an  old  ges- 
tation sac  undergoing  suppuration  and  containing  a  much  macer- 
ated or  disintegrated  fetus.      In  some  cases  of  intraligamentary 

^  Kelly's  "Operative  Gynecology,"  vol.  ii. 

2  "Centralbl.  f.  Gyn.,"'No.  15,  1899. 

3  "Arch.  f.  Gyn.,"  Bd.  Ixiv,  H.  3. 

*  For  a  gooJ  bibliography  of  the  removal  of  extra-uterine  fetuses  through  the 
vagina  and  by  the  rectum  see  J.  T.    Winter,  "  Amer.  Jour.  Obstet.,"  1892,  p.  34. 


444  Extra-uterine  Pregnancy 

pregnancy  it  is  possible  to  open  the  sac  extraperitoneally  by  an 
incision  above  Poupart's  ligament.  It  is  always  advisable,  how- 
ever, to  make  a  preliminary  abdominal  section  to  learn  the  rela- 
tions of  the  gestation  sac. 

Pregnancy  in  One  Horn  of  a  Uterus  Bicornis  or  Unicornis. 
— Pregnancy  in  an  ill-developed  horn  of  a  uterus  unicornis  may 
exactly  resemble  a  tubal  or  interstitial  pregnancy,  and  will  prob- 
ably end  in  rupture  at  the  apex  of  the  cornu.  ^  This  is  particu- 
larly true  if  the  impregnated  ovule  develops  in  a  rudimentary  horn, 
in  which  the  conditions  are  almost  the  same  as  in  a  tube,  except 
that  rupture  takes  place  later.  On  the  other  hand,  a  pregnancy 
in  a  uterus  bicornis  may  terminate  prematurely,  or  even  at  term, 
by  expulsion  of  the  fetus  through  the  vagina. 

The  diagnosis  of  pregnancy  in  a  uterine  horn  is  difficult  or 
impossible.  It  is  mistaken,  usually,  for  tubal  gestation.  The 
removal  of  a  gestation  sac  in  a  rudimentary  uterine  horn  is  com- 
monly easy,  as  a  convenient  pedicle  is  formed  by  its  attachment 
to  the  lower  segment  of  the  better  formed  half  of  the  uterus. 

1  Three  cases  of  pregnancy  in  rudimentary  horns  are  reported  by  Turner,  Werth, 
and  Solin  (Lusk's  "Obstetrics").  Kussmaul  collected  13  cases;  Manierre,  39, 
24  of  which  ended  fatally  by  rupture  ("Amer.  Gyn.  and  Obstet.  Jour.,"  vol.  xv, 
No.  3).  KruU  reports  4  and  Ries  i  ("Arch.  f.  Gyn.,"  Bd.  Ixii,  H.  3,  and  "Amer. 
Jour,  of  Obstet.,"  Jan.,  1901. 


PART   IX. 

DISEASES  OF  THE  OVARIES. 

The  ovary,  the  distinctive  sexual  organ  of  woman,  is  a  gland 
secreting  eggs  during  the  period  of  sexual  activity,  from  about 
the  fifteenth  to  the  forty-fifth  year.  It  is  an  elliptical  shaped 
structure  3-5  cm.  long,  1.5-3  cm.  broad,  0.5-1.5  cm.  thick,  and 
weighs  6-S  grams.  It  is  attached  to  the  posterior  surface  of  the 
broad  ligament  by  the  mesovarium,  a  reduplication  of  the  peri- 
toneum on  the  posterior  surface  of  the  broad  ligament  containing 
blood-vessels,  h'mphatics,  nerves,  and  connective  tissue  entering 
the  interior  of  the  ovary  at  the  hilus.  There  is  a  free  convex 
margin  of  the  ovary  opposite  the  hilus,  a  median  and  a  lateral 
free  surface,  a  uterine  pole  to  which  the  ovarian  ligament  is 
attached,  a  tubal  pole  to  which  the  ovarian  fimbria  is  attached. 
The  ovary  is  the  only  structure  projecting  into  the  peritoneal 
cavity  not  covered  with  peritoneum.  There  is  a  visible  line 
on  the  mesovarium — Farre's  line^ — dividing  the  peritoneum 
from  the  cells  covering  the  ovary.  The  latter  are  columnar, 
resembling  the  epithelium  of  mucous  membrane.  From  these 
cells,  according  to  the  generally  accepted  theory,  are  derived  the 
egg  cords,  or  Pfiiiger's  tubes,  which  are  columnar  extensions  of 
epithelium  into  the  ovary,  dividing  into  spherical  spaces  by  the 
constriction  and  ultimate  complete  division  of  the  tubes  in  their 
length.  There  are  two  layers  in  the  ovary,  distinguishable  mac- 
roscopically,  the  cortical  and  the  medullary.  In  the  former  are 
the  follicles  and  ova  set  in  a  stroma  of  connective  tissue ;  in  the 
latter,  blood-vessels,  lymphatics,  nerves,  connective  tissue  of  a 
looser  structure  than  in  tlie  cortical  layer,  and  unstriped  muscle- 
fibers.  Microscopically  under  the  epithelium  covering  the  ovary 
is  a  fibrous  connective-tissue  capsule,  the  albuginea,  containing 
unstriped  muscle-fibers.  The  albuginea  is  firmly  adherent  to  the 
parenchyma  beneath.  In  the  cortical  layer  under  the  microscope 
are  seen  numerous  small  follicles  and  deeper  within  the  stroma 
larger  ones.  These  follicles,  formed  in  the  manner  already  de- 
scribed, from  Pfiiiger's  tubes,  consist  at  first  during  fetal  life  of 
an  aggregation  of  cells  around  one  cell  specially  developed,  the 

^  Farre,  A.,  "Uterus  and  its  Appendages,"  Todd's  "  Cyc.  of  Anat.  and 
Physiol.,"  vol.  v,  London,  1835-1858. 

445 


446  Diseases  of  the  Ovaries 

ovum,  without  a  capsule  or  liquid  secretion.  Later  in  the  devel- 
opment of  the  follicle  there  is  a  capsule  {tJicca  follicnli^,  a  regular 
arrangement  of  cells  around  the  interior  {jucinbra)ia  gratuilosa),  a 
heaped-up  pile  of  cells  in  one  portion  of  the  periphery  {discus 
proligcriis),  surrounding  a  highly  specialized  cell,  the  ovum. 

The  fully  developed  follicle  is  called  a  Graafian  follicle.  ^  It 
is  0.5—2  cm.  in  diameter,  and  is  visible  as  a  thin-walled  cyst  pro- 
jecting from  the  surface  of  the  ovary.  There  are  18  to  20  of 
these  fully  developed  follicles  of  various  sizes  in  an  ovary.  There 
is  a  vast  number  of  the  smaller  undeveloped  follicles  in  the 
superficial  portion  of  the  cortical  layer.  It  is  estimated  that  the 
two  ovaries  contain  in  round  numbers  100,000  ova.  As  a  fol- 
licle is  distended  by  an  accumulation  of  liquor  folliculi  and  in- 
creases in  size,  it  appears  to  retreat  into  the  interior  of  the  ovary, 
for  it  must  find  additional  room  and  seeks  it  in  the  direction  of 
least  resistance.  It  also  pushes  out  onto  the  free  surface  of  the 
ovary  by  bulging  out  the  albuginea. 

The  arteries  of  the  ovary  are  derived  from  the  ovarian  and 
the  ovarian  branch  of  the  uterine.  They  enter  at  the  hilus  and 
are  ultimately  distributed  around  the  follicles  as  a  capillary  net- 
work. 

The  veins  leaving  the  hilus  empty  into  the  pampiniform 
plexus.  Between  the  layers  of  the  mesovarium  there  is  a  large 
venous  plexus  richly  supplied  with  unstriped  muscle-fibers,  the 
hilbiis  ovarii,  which  is,  in  effect,  erectile  tissue. 

The  lymphatics  leave  the  follicles  with  the  veins  and  empty 
eventually  into  the  lumbar  glands  in  front  of  and  alongside  the 
aorta.  The  nerves  are  derived  from  the  plexus  of  the  ovarian 
artery  ;  they  supply  the  blood-vessel  walls,  but  there  are  reflex 
and  sensory  fibers  in  addition  to  the  vasomotor  nerves.  The 
ovary  lies  normally  in  a  depression  on  the  lateral  pelvic  wall,  the 
ovarian  fossa,  which  is  the  posterior  portion  of  the  obturator 
fossa.  The  ovarian  fossa  is  bounded  behind  by  the  ureter  and 
the  uterine  artery,  above  and  in  front  by  the  umbilical  arteiy. 
There  is  sometimes  a  distinct  pouch  of  peritoneum  on  the  pos- 
terior surface  of  the  broad  ligament  in  which  the  ovary  lies  as 
though  in  a  pocket;  there  is  often  at  least  an  indication  of  this 
arrangement  which  uniformly  exists  in  the  lower  animals. 

The  topographical  relation  of  the  tube  and  ovary  is  important. 
The  former  runs  first  a  horizontal  course,  is  then  directed  upward 
and  next  downward  and  backward  so  that  the  fimbriae  are  spread 
over  the  tubal  pole  and  free  median  surface  of  the  ovary,  often 
concealing  it  completely. 

^  Regnerus  de  Graaf,  "  De  Mulierum  organis  generationii  inservientibus," 
tractatus  novus,  1672. 


Function  of  the  Ovaries  447 

The  ovary  is  supported  and  maintained  in  its  normal  position 
by  the  mesovarium,  the  infundibulopelvic  or  suspensory  ligament, 
the  ovarian  ligament,  and  the  ovarian  fimbria  of  the  tube. 

In  the  neighborhood  of  the  ovary,  between  it  and  the  tube  in 
the  mesosalpinx,  are  three  important  and  interesting  remnants  of 
embryonal  structures — the  parovarium  or  epoophoron,  the  paro- 
ophoron and  Gartner's  canal,  the  remains  of  the  Wolffian  body 
and  its  duct.  The  parovarium  consists  of  6  to  12  little  ducts 
running  parallel  with  one  another  and  emptying  at  right  angles 
into  a  common  duct  (Gartner's  canal)  running  parallel  with  the 
tube.  This  duct  ends  in  a  blind  sac,  but  there  is  often  an  indication 
of  its  continuance  in  the  broad  ligament,  and  in  rare  instances  a 
patent  canal  has  been  traced  to  the  uterine  wall,  to  the  vaginal 
vaults,  and  along  the  lateral  vaginal  walls  to  the  introitus.  The 
walls  of  the  ducts  of  the  parovarium  and  of  Gartner's  canal 
are  composed  of  connective  tissue  and,  it  is  claimed  by  some, 
unstriped  muscle-fibers.  The  internal  lining  is  ciliated  epithe- 
lium. 

The  paroophoron  is  a  microscopical  structure  lying  to  the 
inner  side  of  the  parovarium,  composed  of  rounded  bodies  which 
are  in  part  blind  canals,  in  part  distinct  glomeruli  like  those  of 
the  Wolffian  body.  In  fetal  life  and  in  early  infancy  the  paro- 
ophoron is  visible  to  the  naked  eye.  Its  histological  structure 
is  the  same  as  that  of  the  parovarium. 

The  function  of  the  ovary  is  to  develop,  nourish,  and  set  free 
the  ova,  by  a  process  called  ovulation.  The  Graafian  follicles 
of  greatest  development,  largest  size,  and  protruding  farthest  into 
the  peritoneal  cavity  under  the  stimulus  of  congestion  either  at 
time  of  menstruation  or  as  a  result,  perhaps,  of  coitus,  secrete  a 
still  greater  amount  of  liquor  folliculi,  increasing  the  intrafollicu- 
lar  pressure  to  an  extreme  degree.  At  a  point  on  the  theca  fol- 
liculi of  greatest  prominence  on  the  free  surface  of  the  ovary  a 
degenerative  process  occurs  until  at  this  spot,  the  stigma,  rup- 
ture takes  place,  setting  free  the  liquor  folliculi,  the  discus  pro- 
ligerus,  and  the  ovum,  which  are  discharged  with  considerable 
force  as  the  intrafollicular  pressure  is  suddenly  decreased  by  the 
rupture  of  the  theca  folliculi.  The  discus  proligerus  and  ovum 
are  often  situated  just  below  the  stigma,  but  they  may  occupy  a 
situation  opposite  to  it  or  at  any  point  on  the  periphery  of  the 
follicle. 

The  ovum,  escaping  from  the  ovary,  surrounded  by  its  discus 
proligerus  of  epithelial  cells,  is  caught  in  the  current  of  fluid 
caused  by  the  lashing  of  the  cilia  in  the  tube  and  is  carried  into 
the  tubal  canal  or  it  may  be  discharged  directly  into  the  ampulla 
and  be  caught  at  once  by  the  cilia  of  the  tubal  epithelium.   After 


448  Diseases  of  the  Ovaries 

the  evacuation  of  a  ruptured  Graafian  follicle  a  peculiar  process 
is  observed  resulting  in  the  formation  of  the  so-called  corpus 
luteum  or  yellow  body.  The  internal  layer  of  the  theca  folliculi 
is  enormously  thickened  and  thrown  into  numerous  folds  which 
eventually  fill  the  whole  space  in  the  interior  of  the  follicle.  This 
structure  is  composed  microscopically  of  lutein  cells  (large,  hex- 
agonal cells  like  liver-cells,  containing  a  yellow  substance,  lutein, 
soluble  in  alcohol),  fat  globules,  and  ray-like  extensions  of  fibi'o- 
connective  tissue  septa. 

It  is  a  disputed  point  whether  the  lutein  cells  are  derived 
from  the  internal  layer  of  the  theca  folliculi  or  the  epithelium  of 
the  membrana  granulosa. 

In  case  of  pregnancy  the  yellow  body  is  larger  and  lasts 
longer  than  it  does  if  impregnation  fails  to  occur.  In  from 
thirty  to  one  hundred  and  twenty  days  the  lutein  cells  undergo 
hyaline  and  fatty  degeneration  and  are  absorbed ;  the  theca  fol- 
liculi and  the  connective -tissue  extensions  into  the  lutein  cells 
shrink  into  scar  tissue  (corpora  albicantia  or  fibrosa),  the  site  of 
the  corpus  luteum  being  marked  by  a  depression  and  a  cicatrix  ; 
in  turn  the  corpus  fibrosum  undergoes  hyaline  degeneration  and 
is  absorbed. 

The  purpose  of  the  yellow  body,  as  pointed  out  by  Clark^ 
and  Waldeyer,^  is  to  preserve  the  equilibrium  of  the  circula- 
tion of  the  ovary  and  to  maintain  the  normal  intra-ovarian  pres- 
sure. 

Displacements  of  the  Ovary. — The  ovary  is  not  very  mobile. 
It  does  not  often  leave  its  normal  position  on  the  lateral 
pelvic  wall  for  an  extensive  excursion  in  the  pelvis  or  abdomen, 
although  attached  to  such  easily  movable  structures  as  the 
broad  ligaments  and  uterus.  Under  certain  conditions,  however, 
a  wide  arc  of  movement  is  possible,  but  the  anomalous  position 
thus  acquired  by  the  ovary  is  pathological.  In  salpingo-oophoritis 
the  ampulla  of  the  tube  is  usually  displaced  downward,  back- 
ward, and  inward,  necessarily  carrying  the  ovary  with  it.  In 
retroflexion  of  the  uterus  the  ovarian  ligament  pulls  the  ovary  in 
the  same  directions.  Prolapse  of  the  uterus  may  also  drag  the 
ovary  down.  Tumors  of  the  pelvic  organs  may  cause  remarka- 
ble alterations  in  the  size,  shape,  and  position  of  the  ovary. 
Inflammatory  adhesions  may  fix  it  in  odd  places  in  the  abdominal 
cavity.  For  example,  it  may  adhere  to  the  omentum,  the  parietal 
peritoneum,  or  the  intestines  at  a  high  level  if  an  inflammation 
occurs  in  or  around  it  during  the  early  puerperium.  As  the 
uterus   descends   in  the    course  of  involution   the  ovary  can  not 

^"  Aich.  f.  Anatomic  u.  Physiologie,"  1898. 
2  "  Das  Becken,"  Bonn,  1899. 


Prolapsus  Ovarii  449 

follow  it,  but  remains  fixed,  possibly  far  above  the  pelvic  brim. 
The  normal  descent  of  the  ovary  in  fetal  life  may  fail  to  occur 
and  it  remains  at  the  high  level  it  occupies  in  the  young  embryo.  ^ 
But  in  all  these  conditions  the  malposition  of  the  ovary  is  of  sec- 
ondary importance.  There  are  only  two  displacements  of  the 
ovary  which  of  themselves  require  recognition  and  treatment — 
prolapse,  or  descent  into  Douglas's  pouch,  and  hernia  of  the 
ovary  into  the  thigh,  the  groin,  through  the  pelvic  diaphragm, 
the  thoracic  diaphragm,  the  sciatic  and  obturator  foramina,  and 
the  umbilicus. 

Prolapsus  ovarii  is  a  descent  of  the  ovary  by  an  elongation  of 
the  suspensory  or  infundibulopelvic  ligament.  The  ovary  moves 
in  the  arc  of  a  circle  of  which  the  ovarian  ligament  is  the  radius, 
downward,  inward,  and  backward,  until  it  may  rest  at  the  bottom 
of  an  elongated  Douglas's  pouch  below  the  level  of  the  cervix 
uteri.  Sanger  describes  two  grades  of  ovarian  prolapse  :  par- 
tial, to  the  uterosacral  ligament  ;  total,  to  the  bottom  of  Doug- 
las's pouch.  The  causes  of  the  prolapse  are  abnormal  weight  of 
the  ovary  and  elongation  or  relaxation  of  the  suspensory  liga- 
ment. The  former  may  be  due  to  a  neoplasm,  congestion,  or 
simple  hypertrophy  ;  the  latter  to  childbirth,  flaccidity  of  the 
musculofibrous  abdominal  structures,  increased  intra-abdominal 
pressure,  and  violent  exercise  or  traumatism.  In  the  author's 
experience  the  condition  is  commoner  in  nulliparous  than  in 
parous  women,  and  may  possibly  be  cured  spontaneously  by 
pregnane}'.  The  symptoms  vary  in  different  individuals.  In  some 
the  ovarian  prolapse  is  accidentally  discovered  in  a  pelvic  exam- 
ination. It  has  caused  the  woman  no  inconvenience.  In  the 
majority  of  cases  there  is  pelvic  pain  and  distress,  worse  before 
and  after  menstruation,  in  coitus,  defecation,  and  locomotion.  In 
some  women  the  descent  of  the  ovary  occasions  nausea  and  sick- 
ening pain,  which  completely  incapacitates  them.  A  peculiarity 
of  the  condition  in  some  cases  is  the  return  of  the  ovary  to  a 
normal  position  and  its  retention  there  for  a  considerable 
length  of  time.  If  the  woman  is  too  long  on  her  feet,  strains  at 
stool,  or  is  violently  jolted,  there  is  a  sudden  return  of  the  pro- 
lapse, with  symptoms  that  immediately  inform  the  woman  of  the 
fact.  Usually  a  prolapsed  ovary  remains  permanently  at  its 
abnormally  low  level  in  the  pelvis. 

The  diagnosis  of  a  simple  uncomplicated  prolapse  of  the  ovary 
is  easily  made  by  a  combined  examination,  either  by  the  rectum 
or  the  vagina.  The  ovary  should  be  readily  differentiated  from 
a  small  pedunculated  subperitoneal  fibroid  or  a  mass  of  feces  by 
its  size,  shape,  and  consistency,  and  by  the  sickening  pain  occa- 

1  Sellheim  reports  44  cases  ("Beitr.  z.  Geburtsh.  u.  Gyn.,"  Bd.  v,  p.  177). 
29 


450 


Diseases  of  the  Ovaries 


sioned  by  its  compression  between  the  fingers.  It  can  be  re- 
turned to  almost  a  normal  position,  where  it  may  remain  or  it 
may  immediately  drop  back  again.  The  diagnosis  of  a  case  com- 
plicated by  pelvic  inflammation  or  tumor  is  more  difficult,  but  in 
such  cases  the  malposition  of  the  ovary  is  of  minor  importance. 
If  the  prolapse  of  one  or  both  ovaries  is  associated  with 
retroflexion  of  the   uterus,  the   behavior  of  the  former  afl:er  the 


Fig.  400. — Suspending  the  infundibulopelvic  ligament  to  the  iliac  fascia.      Suspen- 
sory ligament  represented  diagrammatically  much  thicker  than  normal. 


reposition  of  the  uterus  should  be  carefully  observed.  If  they 
return  to  a  normal  position  when  the  uterus  is  replaced,  no  fur- 
ther treatment  of  the  ovaries  is  required.  If  they  remain  pro- 
lapsed after  the  uterus  is  in  good  position,  no  mechanical  or 
operative  treatment  of  the  uterine  displacement  will  cure  the  dis- 
placement of  the  ovaries. 

TrcatDicnt  is  obviously  not  called  for  in  the  absence  of  symp- 


Ovarian   Hernia  or  Ovariocele  451 

toms.  If  the  condition,  as  is  usually  the  case,  is  a  source  of  dis- 
tress or  inconvenience  to  the  patient,  the  treatment  may  be 
palliative  or  curative.  The  former  consists  of  the  digital  reposi- 
tion of  the  ovary  and  the  regular  assumption  of  the  knee-chest 
posture.  Abdominal  massage  and  an  abdominal  belt  are  use- 
ful adjuvants.  Tampons  and  pessaries  are  of  no  service.  They 
can  not  possibly  elevate  the  ovary  sufficiently.  If  palliative  meas- 
ures fail  and  the  symptoms  warrant  it,  the  prolapse  may  be  cured 
by  an  abdominal  section  and  the  suspension  of  the  infundibulo- 
pelvic  ligament  to  the  parietal  peritoneum  over  the  iliopsoas 
muscle,  above  the  pelvic  brim,  and  in  front  of  the  iliac  vessels. ^ 
The  peritoneum  and  underh^ing  fascia  are  picked  up  by  tissue 
forceps  ;  a  round-pointed  curved  needle  threaded  with  fine  silk 
is  inserted  for  about  a  quarter  of  an  inch  under  them  and  two 
turns  are  taken  with  the  same  ligature  around  the  suspensory 
ligament  about  an  inch  to  the  outer  side  of  the  ovary.  As  the 
two  ends  of  the  suture  are  tied,  the  ovary  rises  to  a  perfect  posi-. 
tion.  The  symptomatic  results  of  the  operation  are  excellent. 
With  proper  aseptic  precautions  it  is  free  from  danger.  If  it  is 
necessary  to  suspend  the  uterus  for  retroversion  and  the  ovaries 
remain  prolapsed  after  the  reposition  of  the  uterus,  the  suspen- 
sion of  both  ovaries  not  only  cures  the  ovarian  prolapse,  but 
insures  a  more  perfect  and  permanent  cure  of  the  retroflexion 
than  could  be  secured  by  uterine  suspension  alone.  ^ 

Ovarian  Hernia  or  Ovariocele. — The  ovary  may  form  part  of  the 
contents  of  the  sac  in  inguinal  hernia.  It  has  repeatedly  been 
observed  in  crural  hernia,  both  unilateral  and  bilateral ;  more 
rarely  in  herniae  through  the  pelvic  fascia,  paravaginal  ovariocele  ; 
through  the  sciatic  and  obturator  foramina  and  through  the 
diaphragm. 

In  the  groin  the  ovary  may  be  difficult  to  distinguish  from 
lymphatic  glands,  myoma  of  the  round  ligament,  hydrocele,  or 
the  more  usual  contents  of  the  hernial  sac.  Its  size,  consistency, 
and  sensitiveness,  but  most  of  all  the  premenstrual  swelling  and 
increased  pain,  are  distinctive.  The  ovary  in  an  inguinal  hernia 
is  often  diseased  or  at  least  chronically  congested  and  enlarged. 
It  shows  a  tendency  in  this  situation  to  malignant  degeneration. 
It  is  frequently  adherent.  There  is  usually  some  malformation 
of  the  genitalia,  as  uterus  unicornis  or  bicornis.  The  hernia  may 
be  congenital   or  acquired,  rnore   commonly  the  former.      In   the 

1  The  credit  of  devising  this  operation  belongs  to  Sanger  ("Centralbl.  f.  Gyn.," 
1896,  No.  9),  although  many  surgeons,  including  the  author,  had  independently  sus- 
pended a  prolapsed  ovary  before  the  appearance  of  Sanger's  paper. 

2  The  author  has  attended  in  confinement  a  patient  on  whom  he  had  performed 
this  operation  two  years  previously.  The  symptomatic  cure  is  perfect ;  the  ovaries 
and  uterus  remain  in  normal  position. 


452 


Diseases  of  the  Ovaries 


latter  case  the  hernia  is  unilateral,  the  ovary  is  easily  replaced, 
and  there  are  a  knuckle  of  bowel  and  omentum  in  the  canal ;  the 
tube  often  remains  in  the  abdominal  cavity.  In  congenital  cases 
the  tube  and  the  uterus,  especially  one  horn  of  a  malformed 
organ,  are  often  found  in  the  sac.  In  bilateral  ovarian  hernia  the 
woman  is  usually  sterile  (Olshausen). 

No  treatment  is  called  for  in  favorable  cases  except  the  repo- 
sition of  the  hernia  and  the  adjustment  of  a  truss.  If  the 
ovary  is  enlarged,  diseased,  or  adherent ;  if  a  truss  is  inefficient, 


Fig.  40 r. — Ovary  converted  into  thin-walled  retention  cysts  of  the  Graafian 
follicle  (hydrops  follicularis),  into  each  of  which  there  has  been  an  intrafollicular 
hemorrhage. 

or  if  there  is  decided  discomfort,  the  sac  should  be  laid  open, 
the  ovary  and  other  contents  returned  within  the  abdomen,  and  a 
radical  operation  (Bassini's)  for  hernia  performed.  If  the  ovary 
is  distinctly  diseased  or  is  much  injured  in  separating  adhe- 
sions, its  removal  is  indicated.  If  an  ovarian  hernia  is  discovered 
in  the  course  of  a  celiotomy,  it  may  be  pulled  back  into  the  ab- 
dominal cavity,  the  hernial  ring  being  obliterated  by  sutures. 

Circulatory  disturbances  of  the  ovary  result,  on  the  one  hand, 
in  congestion,  hyperti"ophy,  edema,  and  hemorrhage  ;  on  the  other 
hand,  in  atrophy  and  necrosis. 


Ovarian   ConQ-estion 


45. 


Ovarian  congestion  has  many  causes.  It  is  physiological  in 
the  few  days  preceding  menstruation,  in  pregnancy,  and  during 
coitus.      If  it  is  intensified  or  long  continued,  it  is  likely  to  induce 


Fig.  402. — Same  as  figure  401  ;   the  blood-clot  has  been  turned  out  of  the  section  on 
the  left,  and  has  been  left  in  situ  on  the  right. 


Fig.  403. — Ovarian  retention  cyst :  O,  Retention  cyst  (hydrops  follicularis)  associated 
with  a  parovarian  cyst  ;   Po,  parovarian  cyst. 


pathological  changes.  Venereal  excesses  or  abnormalities,  such 
as  interrupted  coitus  ;  any  of  the  causes  of  pelvic  congestion  in 
general,  as  physical  or  mental  overexertion,  especially  at  the 
menstrual  periods  ;   displacement  of  the  uterus,  exposure  to  cold 


454 


Diseases  of  the  Ovaries 


during  the  periods,  may  lead  to  chronic  parenchymatous  hypertro- 
phy, or  cirrhosis,  if  the  congestion  is  gradual  in  onset  and  long 
continued,  or  to  edema  and  hemorrhages  if  the  congestion  is 
acute  and  intense. 

Parenchymatous   hypertrophy   is   observed   in   the   so-called 
"cystic  ovaries"  in  which  the  Graafian  follicles  are  much  enlarged 


Fig.  404. — Whole  ovary  occupied  by  two  corpus  luteum  cysts. 


Fig.  405. — Same  as  figure  404,   laid  open. 


and  the  ovary  presents  an  irregular  surface  with  protruding  folli- 
cles of  varying  sizes.  The  ultimate  stage  of  this  condition  is  a 
true  retention  cyst  of  a  follicle  converting  the  ovary  into  a  small 
cystic  tumor.  In  such  a  case  the  distention  of  the  affected  folli- 
cle is  sufficient  to  reduce  the  rest  of  the  ovary  by  pressure  to  an 
atrophic  mass  forming  part  of  the  cyst-wall.  The  process  is  neces- 
sarily self-limiting  because  the   liquor  folliculi  produced  by  the 


Ovarian   Coneestion 


455 


Fig.  406. — Cystic  corpus  luteum  :   cav.  Cavity  of  cyst ;   iv,  wall  of  cyst,  showing  con- 
volutions (McConnell  and  J.  C.  Hirst). 


Fig.  407. — Wall  of  corpus   luteum  ;  w.  Wall  of  corpus  luteum,  showing  fan-shaped 
plications  (McConnell  and  J.  C.  Hirst). 


456  Diseases  of  the  Ovaries 

epithelium  of  the  follicles  reaches  only  a  moderate  amount  when 
the  membrana  granulosa  itself  becomes  atrophic  by  reason  of  the 
intrafoUicular  pressure.  Ordinarily  but  one  follicle  is  affected 
and  the  cyst  is  unilocular.  Several  follicles  may  be  the  seat  of 
retention  cysts,  in  which  case  the  ovary  is  converted  into  a  small 
multilocular  cystic  tumor.  If  one  of  these  hypertrophied  folli- 
cles bursts,  a  very  large  corpus  luteum  is  developed  and  there  is 
likely  to  be  formed  a  corpus  liLtaun  cyst  in  which  the  fluid  is  fur- 
nished partly  by  the  much  hypertrophied  and  multiplied  lutein 
cells,  partly  by  extravasated  blood.  One  or  two  such  cysts  may 
occup}'  a  whole  ovary.  A  long-continued  congestion  of  the 
ovary,  as  in  any  of  the  body  organs,  results  in  overgrowth  of 
connective  tissue,  which  in  time  shrinks  into  a  scar-like  tissue — 
cirrhosis.  In  the  first  stage  of  the  connective-tissue  overgrowth 
the  organ  is  enlarged;  in  the  secondary  stage  it  shrinks  and  be- 
comes unnaturally  firm  in  consistency.  It  is  tough  in  feel  and 
appearance,  and  its  surface  is  marked  by  superficial  sulci  dividing 
it  into  apparent  lobes.  There  may  be  no  prominent  follicles  and 
no  corpora  lutea;  corpora  albicantia  are  numerous;  the  paren- 
chyma is  atrophic.      The  albuginea  is  thickened. 

Acute  and  intense  congestion  may  cause  edema  and  hemor- 
rhage. The  former  is  only  temporary,  but  may  be  excessive  and 
may  be  associated  with  ascites. 

Ovarian  hemorrhage  displays  three  forms;  interstitial,  fol- 
licular, and  diffuse.  The  first  occurs  from  the  capillary  network 
around  the  follicles,  which  may  be  destroyed  by  the  pressure  of 
the  extravasated  blood.  The  second  occurs  either  as  an  extrav- 
asation from  the  theca  interna  under  the  membrana  granulosa  or 
as  a  hemorrhage  into  the  follicular  cavity,  bursting  its  way  through 
the  epithelium  (Fig.  402).  In  the  third  form — hcematoma  ovarii 
— the  whole  ovary  is  converted  into  a  blood-sac.  The  organ  has 
the  consistency  and  somewhat  the  appearance,  on  section,  of  a 
spleen.  The  ovarian  structure  proper  disappears  and  the  ovary 
is  virtually  destroyed.  A  diffuse  or  intrafoUicular  hemorrhage 
may  result  in  an  intra-abdominal  bleeding  by  rupture  of  the 
ovarian  capsule,  possibly  with  a  fatal  result,  or  more  likely  caus- 
ing an  intraperitoneal  hematocele. 

The  symptoms  of  ovarian  congestion  are  associated  usually 
with  those  of  metritis  and  endometritis.  There  is  usually  ovarian 
pain,  wor.se  just  before  and  after  menstruation,  centered  usually 
above  the  middle  of  Poupart's  ligament,  and  worse  as  a  rule  on 
the  left  side.  "  Mittelschmerz  "  is  not  infrequent  and  there  may 
be  extreme  dysmenorrhea.  In  cirrhosis  of  the  ovaries  the  dys- 
menorrhea with  scanty  menstruation  is  often  most  distressing. 
As  in  all  the  diseases  of  the  pelvic  organs,  but  most  particularly 


Ovarian   Hemorrhage 


457 


of  the  ovaries,  there  is  hkely  to  be  a  long  train  of  reflex  and 
neurotic  disturbances,  such  as  pain  in  the  head  or  nape  of  the 
neck,  digestive  disturbances,  backache,  and  pain  in  the  breasts. 
In  some  patients  an  intense  premenstrual  mastalgia  is  the  most 
prominent  and  perhaps  the  only  symptom  of  ovarian  congestion. 
On  examination  the  enlarged  and  hyperesthetic  ovaries  may  be 
palpated.  The  increased  size  and  weight  of  the  organs  often 
cause  some  displacement,  perhaps  to  the  grade  of  total  prolapse. 
The  physical  peculiarities  of  cirrhotic  ovaries  in  favorable  cases 
can  be  plainly  distinguished  in  a  bimanual  examination.      In  par- 


Fig.  408. — Hematoma  ovarii  from  thrombosis  and  complete  occlusion  of  the  sper- 
matic vein. 


enchymatous  hypertroph}^  it  is  a  not  infrequent  experience  to  feel 
an  enlarged  follicle  or  small  retention  cyst  burst  during  the  ex- 
amination. The  physical  signs  of  ovarian  congestion  or  chronic 
inflammation  may  be  entirely  absent.  An  exploratory  abdominal 
section  is  justifiable  and  necessary  if  persistent  ovarian  symptoms 
severe  enough  to  seriously  impair  the  individual's  health  can  not 
be  explained  by  the  physical  examination. 

The  treatment  of  ovarian  congestion 
without  operative  interference  unless  the 
already  undergone  radical  alteration. 

It  is  most  important  to  discover  and  to  eliminate  the  cause. 


is    usually   successful 
)varian   structure  has 


458  Diseases  of  the   Ovaries 

Violation  of  the  laws  of  sexual  hygiene  or  masturbation  must 
be  investigated.  Displacements  of  the  uterus,  overexertion, 
mental  or  physical,  and  imprudence  at  the  menstrual  periods, 
a  sedentary  life,  and  obstinate  constipation  must  be  corrected. 
Heart  and  liver  diseases  or  any  other  mechanical  interference  with 
the  pelvic  circulation  should  be  looked  for. 

In  addition  to  removing  the  cause,  if  possible,  glycerin  tam- 
pons, hot-water  douches  (a  gallon  at  120°  F.),  laxatives,  and  the 
regular  assumption  of  the  knee-chest  posture  twice  a  day  often 
give  great  relief  and  may  dissipate  the  symptoms  in  a  few  days. 
If  the  ovaries  have  been  structurally  altered  by  retention  cysts, 
cirrhosis,  or  hemorrhage,  no  treatment  short  of  surgical  interven- 
tion can  be  of  any  service.  The  patient  and  physician  must 
choose  between  a  continuance  of  the  symptoms  and  an  abdom- 
inal section.  Even  if  such  changes  can  not  be  demonstrated  by 
physical  signs,  the  inference  that  they  have  occurred  is  justified 
if  typical  symptoms  persist  unabated  in  spite  of  careful  treat- 
ment. The  severity  of  the  symptoms  naturally  determines  the 
course  to  be  pursued.  If  the  operative  treatment  is  selected, 
there  should  be  an  understanding  with  the  patient  that  no  ovarian 
tissue  shall  be  unnecessarily  removed  ;  but  permission  should 
be  obtained  for  the  radical  removal  of  both  organs  if  such  a 
course  is  necessary  for  the  restoration  of  the  patient's  health.  On 
opening  the  abdomen  ^  it  is  possible  to  determine  what  is  really 
required.  Puncture  of  hypertrophied  follicles  may  be  all  that  is 
necessary.  Exsection  of  a  wedge-shaped  piece  of  structurally 
altered  ovary,  uniting  the  wound  with  interrupted  catgut  sutures, 
and  leaving  the  remainder  of  the  organ  may  be  indicated.  If  the 
ovaries  are  prolapsed,  they  should  be  suspended.  If  the  whole 
ovary  is  occupied  by  a  retention  cyst ;  if  it  is  in  the  last  stages  of 
cirrhosis  or  the  seat  of  diffuse  hemorrhage,  it  must  be  removed. 
The  appendix  should  invariably  be  examined  and  removed  if 
diseased.  Many  a  case  of  supposed  ovarian  congestion  or  in- 
flammation in  women  is  really  one  of  chronic  appendicitis,  often 
complicated  by  right-sided  ovarian  irritation,  congestion,  or  inflam- 
mation. Even  if  the  appendix  is  not  diseased  a  fecal  concretion 
is  often  felt  in  it  which  can  be  stripped  back  into  the  large  bowel, 
thus  removing  a  likely  cause  of  inflammation  in  the  future. 

Atrophy  of  the  ovary  before  the  menopause  may  be  a  conse- 
quence of  pressure  from  pelvic  tumors,  varicocele  of  the  broad 
Hgament,  ovarian  hemorrhage,  infection,  systemic  diseases  such  as 

'  Vaginal  section  for  this  purpose  is  properly  losing  its  vogue.  It  is  impossible 
to  palpate  and  inspect  the  pelvic  and  abdominal  organs,  including  the  appendix,  as 
thoroughly  by  this  means,  and  there  are  certain  necessary  steps  in  the  treatment,  such 
as  suspension  of  the  ovaries,  which  are  impossible  by  the  vaginal  route. 


Intlammations   of  the   Ovary  459 

typhoid  fever,  diabetes,  anemia,  chronic  nephritis,  phthisis,  myxe- 
dema, akromegaly,  the  neuroses,  and  obesity.  It  may  accompany 
SLiperinvolution  or  atrophy  of  the  uterus.  The  subjective  symp- 
toms are  amenorrhea,  absence  of  menstrual  moHmina,  and  steril- 
ity. A  bimanual  examination  reveals  the  small  size  of  the  ovar)-, 
associated  usually  with  an  atrophied  uterus. 

Necrosis  of  the  ovary  is  the  result  of  a  complete  deprivation 
of  blood-supply  as  a  consequence  of  thrombosis  or  obstruction 
of  the  vessels  from  compression,  infection,  or  most  often  from  a 
twisted  pedicle.  The  outer  third  of  the  tube  and  the  ovary  may 
be  absorbed  and  completely  disappear  or  be  represented  by  a 
.  small  mass  of  degenerated  tissue  (Fig.  388). 

Inflammations  of  the  Ovary, — Acute  oophoritis  is  the  result 
of  microbic  infection.  ^  It  is  most  commonly  seen  in  puerperal 
streptococcic  infection.  Gonorrheal  infection  is  next  in  fre- 
quency, as  a  cause  of  acute  ovarian  inflammation.  Other  micro- 
organisms discovered  in  inflamed,  suppurating  ovaries  are  the 
colon  bacillus,  the  pneumococcus,  the  tubercle  bacillus,  and  the 
typhoid  bacillus.  Pfannenstiel  quotes  three  cases  of  posttyphoid 
ovarian  abscess, ^  in  one  of  which  diplococci  were  also  found. 
Morris  Lewis  and  Le  Conte^  report  two  interesting  cases  in  the 
Pennsylvania  Hospital  and  have  collected  seven  others.  It  is  not 
yet  demonstrated  that  typhoid  bacilli  are  pyogenic,  so  that  there 
may  be  a  mixed  infection  in  these  cases.  The  usual  point  of 
entrance  in  the  ovary  for  infecting  bacteria  is  through  the  blood- 
vessels and  lymphatics  of  the  hilus.  Gonorrheal  infection,  how- 
ever, most  commonly  occurs  in  a  recently  ruptured  Graafian  folli- 
cle by  way  of  the  tubal  ostium.  Tuberculous  infection  also  may 
occur  from  the  tube  or  the  peritoneum,  but  it  is  most  commonly 
found  in  the  ovarian  stroma.  Primary  tiiberadosis  of  the  ovary  \s 
exceedingly  rare,  if  indeed  it  has  ever  been  clearly  demonstrated. 
The  pathological  processes  common  to  all  forms  of  acute  infec- 
tious oophoritis  are  hyperemia,  edema,  leukocyte  infiltration,  es- 
pecially along  the  blood-vessels,  and  suppuration  in  the  form  of 
one  localized  abscess,  multiple  abscesses,  or  of  diffuse  suppura- 
tion. The  result  of  ovarian  suppuration  is  often  fatal,  especially  in 
the  streptococcic  puerperal  variety.  Gonorrheal  ovarian  abscesses 
are  scarcely,  if  at  all,  more  dangerous  to  life  than  the  gonor- 
rheal pus-tube  with  which  they  are  associated.  A  curious  result 
noted     after    the    operative     treatment    of    posttyphoid     ovarian 

^  It  has  been  asserted  that  phosphorus-  and  arsenic-poisoning  cause  acute  oopho- 
ritis ;  also  that  an  abortifacient  employed  in  India  does  the  same.  These  forms  of 
acute   ovarian  inflammation,   if  they  occur,  have  little  interest  for  the  gynecologist. 

2  Veit's  "Handbuch,"  vol.  iii,  p.  272. 

3  "  Infection  of  Ovarian  Cysts  during  Typhoid  Fever,"  "  Amer.  Jour.  Med. 
Sci.,"  Oct.,  1902. 


460  Diseases  of  the  Ovaries 

abscesses  is  a  recurrence  of  the  typhoid  symptoms.  Ah  forms 
of  acute  ovarian  inflammation  and  suppuration  may  exhibit  a 
spontaneous  cure  by  destruction  of  the  ovarian  substance  and 
shrinkage  of  the  organ  or  by  encapsulation  of  inspissated  or 
caseous  pus. 

The  symptoms  are  those  of  acute  infectious  pelvic  peritonitis 
and  tubo-ovarian  inflammation.  It  is  often  impossible  to  determine 
before  opening  the  abdomen  how  much  the  ovary  is  involved  in 
the  process.  There  are  fever,  accelerated  pulse,  tympany,  and 
by  combined  examination  there  is  found  a  pelvic  exudate,  a  large 
fixed  mass  to  either  side  of  or  behind  the  uterus,  in  which  it  is 
not  usually  practicable  to  differentiate  the  ovary  from  the  oc- 
cluded, distended  tube.  Occasionally  the  swollen  ovary  may  be 
mapped  out.  The  agonizing  pain  of  acute  oophoritis  is  a  valu- 
able diagnostic  symptom.  There  is  nothing  in  the  pelvis  so  ex- 
quisitely sensitive  as  an  inflamed  ovary,  except  a  tubal  gestation 
sac.  Much  greater  pain  and  sensitiveness  than  are  usual  in  pelvic 
inflammations  point,  therefore,  to  the  likelihood  of  ovarian  inflam- 
mation and  suppuration.  The  treatment  of  acute  suppurative 
oophoritis  is  the  removal  of  the  infected  ovary  by  an  abdominal 
section.  In  all  forms  of  infection  except  the  streptococcic  the 
operation  promises  a  good  result  and  often  saves  the  patient  from 
imminent  danger.  In  streptococcic  puerperal  infection  the  opera- 
tion is  equally  demanded,  but  there  is  the  grave  disadvantage  that 
the  infected  pelvic  connective  tissue  of  the  mesosalpinx  is  ex- 
posed in  the  stump  after  the  removal  of  the  ovary  and  the 
streptococci  let  loose  in  the  peritoneal  cavity  may  rapidly  develop 
a  fatal  peritonitis.  One  means  of  escaping  this  danger,  in  the 
author's  experience,  is  to  avoid  mass  ligatures  and  to  thoroughly 
drain  the  pelvis  by  a  glass  tube  and  gauze  packing  which  com- 
pletely fills  the  pelvic  cavity.^  (See  page  633.)  Another  is  to 
use  Downes'  cautery  clamp  on  the  stump   (p.  589)- 

If  acute  oophoritis  does  not  reach  the  suppurative  stage  it  may 
subside  completely  after  rest  in  bed,  the  ice-water  coil  over  the 
hypogastrium,  laxatives,  and  hot  vaginal  douches.  No  further 
treatment  is  required.  If  the  acute  inflammation  subsides  and 
leaves  a  disorganized  ovary  embedded  in  dense  peritoneal  adhe- 
sions, radical  operative  treatment  may  be  demanded. 

Tuberculosis  of  the  ovaries  is  exceedingly  rare.  A  case  of 
primary  infection  is  reported  by  Jacobs. ^  The  other  recorded 
cases  were  secondary  to   tuberculous  inflammation  of  the  tubes, 

1  In  one  of  my  cases  the  patient  was  operated  on  in  a  comatose  condition,  with 
a  pulse  of  140  and  a  temperature  of  104°.  In  twenty-four  hours  the  patient's  mind 
was  clear  and  the  fever  had  subsided.  In  that  time  more  than  a  pint  of  serous  pus 
swarming  with  streptococci  had  drained  from  the  pelvic  connective  tissue. 

2  "Centralbl.  f.  Gyn.,"  1893,  p.  75. 


Chronic  Oophoritis 


461 


peritoneum,  and  intestines.  The  stroma  is  mainly  involved,  but 
cheesy  masses  may  be  found  in  corpora  lutea  or  ruptured  Graafian 
folHcles. 

Actinomycosis  of  the  ovaries  has  been  observed  in  connec- 
tion with  infection  of  the  genitalia,  peritoneum,  and  liver.  The 
ovary  is  described  as  "worm-eaten,"  with  numerous  small  foci  of 
suppuration  in  which  colonies  of  actinomyces  were  found.  ^ 

Chronic  Oophoritis. — Much  that  has  been  said  of  chronic 
congestion  applies  to  chronic  inflammation  of  the  ovaries.  The 
later  stage  of  long-continued  congestion  is  inflammation  with  in- 
volvement, more  particularly,  of  the  stroma.  The  disease  is  usually 
bilateral.  The  causes  of  chronic  inflammation  are  any  of  the 
causes  of  long-continued  congestion,  a  previous  acute  oophoritis, 
inflammation  of  neighboring  organs,  particularly  of  the  tubes  and 
of  the  pelvic  peritoneum.      Oophoritis  is   often  associated  with 


PMg.  409.  — Cirrhosis  of  ovary. 


Pig.  410. — Cirrhosis  of  ovary. 


fibroma  and  carcinoma  of  the  uterus.  The  structures  involved 
in  the  inflammation  are  the  stroma  predominantly,  but  often  the 
parenchyma  also.  There  is  an  overgrowth  of  connective  tissue 
and  a  follicular  hypertrophy.  The  stroma  is  thickened,  the 
blood-vessels  in  it  are  enlarged  and  may  be  obliterated  by  endar- 
teritis obliterans.  There  is  a  tendency  to  formation  of  Graafian 
follicle  retention  cysts  (the  so-called  cystic  ovaries).  There  are 
few,  if  any,  corpora  lutea,  but  numerous  corpora  fibrosa,  which 
are  formed  by  the  degeneration  of  the  follicular  epithelium,  the 
absorption  of  the  liquor  folliculi,  and  an  invasion  of  the  follicular 
space  by  connective  tissue  without  the  formation  of  a  lutein-cell 
membrane.  The  whole  ovary  is  enlarged,  of  firm  consistency, 
except  in  the  region  of  the  retention  cysts,  and  heavy.  The 
superficial  epithelium  is  unaltered,  but  the  ovary  is  frequently 
embedded  in  peritoneal  adhesions  which  may  completely  envelop 

1  Stewart  and  Muir,  "Edinburgh  Hospital  Reports,"  vol.  i. 


462  Diseases  of  the  Ovaries 

it.  This  fact  in  connection  with  the  thickened  albuginea,  and  the 
degeneration  of  the  folHcles  (corpora  fibrosa)  explain  the  sterility 
that  is  a  frequent  consequence  of  chronic  oophoritis. 

The  symptoms  are  ovarian  pain,  aggravated  at  the  menstrual 
period,  especially  before  and  after  the  flow ;  pain  on  defecation, 
coitus,  or  a  sudden  jolt  or  jar  from  any  cause,  possibly  an  inter- 
menstrual pain  ("  Mittelschmerz  "),  long-continued  and  profuse 
menstruation,  and  in  the  ultimate  stages  of  the  disease  scanty 
menstruation  and  amenorrhea  with  possibly  a  premature  meno- 
pause. There  is  no  disease  of  the  pelvic  organs  so  often  asso- 
ciated with  reflex  and  neurotic  symptoms  of  the  most  varied  kind. 

The  diagnosis  of  chronic  oophoritis  is  made  by  the  subjective 
sx'mptoms  and  the  physical  signs.  The  latter  are  determined  by 
a  bimanual  or  combined  examination,  in  which  the  increased  size, 
the  density,  and  the  unnatural  sensitiveness  of  the  ovary  are  ap- 
parent. If  there  are  peritonitic  adhesions  (peri-oophoritis)  the 
fixed  position  or  limited  mobility  of  the  ovary  is  demonstrable. 
In  such  a  case  there  is  usually  also  some  degree  of  prolapsus 
ovarii  which  makes  it  more  accessible  to  the  combined  examina- 
tion. 

In  the  ultimate  stages  of  chronic  oophoritis  with  shrinkage  of 
the  ovary  (ovarian  cirrhosis)  the  diagnosis  may  be  more  difficult, 
but  in  a  case  favorable  for  examination,  the  dense  consistency, 
small  size,  and  irregular  surface  may  be  clearly  appreciated. 

The  treatment  should  aim  at  obviating  the  causes  of  chronic 
congestion,  if  possible.  If  there  is  much  structural  alteration  of 
the  ovary,  the  oophoritis  itself  is  incurable.  It  is  always  an 
anxious  question  in  the  individual  case  to  decide  upon  the  neces- 
sity for  oophorectomy.  The  gravity  of  the  symptoms,  the  age 
and  social  state,  the  incapacity  of  the  patient,  especially  if  she  is 
of  the  working  classes,  must  decide  patient  and  operator  in  the 
individual  case. 

After  the  abdomen  is  opened  it  may  be  found  practicable  to 
obtain  a  s\'mptomatic  cure  by  releasing  adhesions,  puncturing  re- 
tention cysts,  excising  wedge-shaped  pieces  of  the  most  diseased 
portions  of  the  ovaries,  and  possibly  suspending  them,  at  the 
same  time  inspecting  all  the  neighboring  pelvic  and  abdominal 
structures  and  removing  any  source  of  continued  irritation  or 
congestion,  as  a  diseased  tube,  varicocele  of  the  broad  ligament, 
or  an  inflamed  appendix.  If  the  patient  is  a  young  woman 
with  prospects  of  matrimony  and  maternity,  every  effort  should 
be  made  to  conserve  ovarian  tissue,  at  the  risk  of  a  persis- 
tence of  some  of  the  symptoms  or  of  a  second  operation.  If, 
on  the  contrary,  she  has  borne  .several  children,  if  she  is  likely 
to  remain  single,  if  invalidism  in  her  case  means  pauperism,  if  she 


Neoplasms  of  the   Ovary 


46: 


is  the  support  of  dependent  relatives,  the  main  object  must  be  a 
radical  removal  of  all  source  of  future  pain  and  incapacity  even 
if  a  premature  menopause  and  sterility  are  the  consequence. 


NEOPLASMS  OF  THE  OVARY. 

Among  the  numerous  classifications  of  ovarian  tumors,  that 
of  Pfannenstiel  is  the  most  convenient  and  scientific. 

Ovarian  tumors  are  either  parenchymatogenous  or  stromatog- 
enous.     The  parenchymatogenous   tumors  may  be  derived  from 


Fig.  411. — Simple  serous  cyst  of  ovary. 

the  epithelium  of  the  ovary  or  from  the  ovule  (ovulogenous). 
The  parenchymatogenous  tumors  are  simple  serous  cysts,  serous 
and  pseudomucin  cystadenomata,  carcinomata,  dermoids,  and  ter- 
atomata,  the  last  two  being  ovulogenous. 

The  stromatogenous  tumors  are  fibromata  and  fibromyomata, 
sarcomata,  endotheliomata,  angiomata,  enchondromata,  and  myo- 
mata. 

There  may  be  a  combination  of  several  of  the  above- 
named  tumors  in  one  ovary.  All  of  the  cystic  growths  may 
develop  a  papillary  hyperplasia  of  the   epithelium.     Any  of  the 


464  Diseases  of  the  Ovaries 

ovarian  tumors  may  grow  between  the  layers  of  the  broad  liga- 
ment and  may  consequently  be  intraligamentary.  Serous  cyst- 
adermomata  have  the  greatest  tendency  to  this  form  of  growth  ; 
pseudomucin  cysts,  the  least.  Dermoid  cysts  are  also  very  rarely 
intraligamentary.  Obviously  a  gross  division  o^  ovarian  tumors 
may  be  made  into  the  cystic  and  the  solid. 

Simple  serous  cysts  of  the  ovary  differ  from  a  retention  cyst 
of  a  Graafian  follicle  (hydrops  follicularis)  in  possessing  an  epi- 
thelial lining  unlike  that  of  the  follicle,  and  displaying  active 
proliferation.      They  are  differentiated  from  the  cystadenomata  by 


f  J<^. 


\'(>/,,J  '  'i        ^ / 


a.^"  Hit- 


Fig.  412. — Wall  of  simple  serous  cyst :  Fig.     413.  —  Syncytium-like 

■a,  Epithelium;  d,  cyst-wall  with   numerous  epithelium  of  simple  serous  cyst 

blood-vessels  (Pfannenstiel).  (Pfannenstiel). 


the  absence  of  proliferating  gland  tubules  in  the  cyst-wall  and  by 
the  different  character  and  behavior  of  the  epithelium.  They  are 
lined  by  a  single  layer  of  columnar  epithelial  cells  which  occa- 
sionally take  on  a  syncytium-like  form. 

The  cyst  is  usually  unilocular  and  at  most  has  but  two  or 
three  loculi.  It  is  almo.st  always  pedunculated,  but  maybe  intra- 
ligamentary. The  cyst-wall,  composed -of  connective  tissue,  is 
thin.  The  tumor  is  ordinarily  moderate  in  size,  but  may  reach 
huge  dimensions.  The  fluid  is  a  serum  rich  in  albumin,  but  with- 
out a  trace  of  pseudomucin ;  it  does  not  coagulate  on  exposure 


Pseudomucin   Cystadenomata  465 

to  the  atmosphere.  Quite  frequently  there  is  a  papillary  out- 
growth of  the  epithelium  in  the  interior  of  the  cyst. 

The  origin  of  the  tumor  is  most  hkely  a  pathological  trans- 
formation of  the  follicular  epithelium  and  there  is  usually  a  his- 
tory of  previous  ovarian  inflammation. 

Simple  serous  cysts  of  the  ovary  are  absolutely  benign.  Their 
contents  ma}^  be  discharged  into  the  abdominal  cavity  without 
harm.  There  is  never  a  recurrence  nor  an  implantation  metastasis 
after  their  removal. 

In  their  clinical  features  they  are  very  like  parovarian  cysts, 
for  which  they  are  often  mistaken. 

The  growth  is  usually  unilateral.  The  pedicle  of  the  tumor, 
as  of  all  pedunculated  ovarian  cysts,  is  composed  of  the  tube,  the 
mesovarium,  the  ovarian  ligament,  and  the  infundibulopelvic  liga- 
ment. 

The  mode  of  growth  is  also  hke  that  of  all  pedunculated 
ovarian  cysts.  At  first  the  tumor  moves  inward  and  downward 
into  Douglas's  pouch,  and  then,  as  its  size  increases,  upward  and 
outward,  making  a  twist  in  the  pedicle  of  90  degrees,  the  turn 
being  always  toward  the  side  from  which  the  tumor  sprang.  The 
uterus  is  commonly  pushed  backward  as  the  tumor  ascends  into 
the  abdomen.  The  intestines  are  displaced  upward  and  backward, 
the  small  intestines  being  mainly  behind  the  tumor,  the  large 
bowel  surrounding  it  above  and  in  the  flanks,  giving  rise  to  the 
so-called  corona  of  resonance  around  an  ovarian  cyst  on  abdomi- 
nal percussion.  The  rate  of  growth  in  simple  serous  cysts  is 
slow.  After  reaching  moderate  dimensions  there  may  be  a  com- 
plete cessation  of  further  growth,  most  likely  from  atrophic  and 
degenerative  changes  in  the  lining  epithelium  due  to  intracystic 
pressure.  If  tapped  or  ruptured  the  cyst  usually  refills.  Cases 
are  recorded,  however,  of  cure  after  rupture.  ^ 

Ascites  may  accompany  any  of  the  ovarian  tumors.  If  the 
serous  exudate  into  the  peritoneal  cavity  is  .excessive  and  is  asso- 
ciated with  pleural  effusion,  as  it  almost  always  is  if  the  ascites  is 
marked  and  long  continued,  the  ovarian  tumor  is  probably  malig- 
nant or  else  there  may  have  been  a  rupture  of  a  proliferating  cyst 
and  an  extension  of  the  epithelial  growth  to  the  peritoneum. 
Ascites,  however,  is  not  always  a  sign  of  malignancy  or  rupture; 
it  is  associated  with  a  fibroma  of  the  ovary  and  may  even  be  ob- 
served with  simple  serous  cysts,  though  it  is  least  commonly 
associated  with  such  ovarian  tumors. 

Pseudomucin  Cystadenomata. — The  ovarian  cystadenomata 

^  The  author  has  seen  a  pedunculated,  thin-walled  ovarian  cyst  rupture  as  the 
patient,  alighting  from  a  street  car  to  enter  the  hospital   for  operation,  fell  upon  her 
abdomen.      The  tumor  disappeared  and  did  not  return. 
30 


466 


Diseases  of  the   Ovaries 


are  characterized  by  the  formation  of  gland  tubules,  rapidly  pro- 
liferating, lined  with  a  secreting  epithelium  in  a  single  layer  of 


Fig.  414. 


Fig.  415. 


Fig.  416. 


Figs.  414,  415,  416. — The  stages  of  pseudomucin  formation  and  excretion.  In 
figure  414,  at  a  the  cells  are  inactive,  the  contents  are  mainly  albuminous.  In 
figure  415  the  epithelium  is  longer,  the  albuminous  material  is  collecting  around  the 
nuclei  at  the  bases  of  the  cells,  pseudomucin  is  formed,  but  not  so  sharply  differen- 
tiated from  the  albumin.  In  figure  416  the  pseudomucin  is  perfectly  transparent  and 
sharply  differentiated  from  the  albuminous  cell  contents.  The  pseudomucin  is  dis- 
charged from  the  interior  of  the  cell,  which  is  not  destroyed  or  desquamated,  but 
begins  again  to  accumulate  the  pseudomucin.  The  greatest  quantity  of  this  material 
is  seen  in  the  cells  at  b  in  figure  416;   there  is  least  at  b  in  figure  414  (Pfannenstiel). 


cells,  becoming  rapidly  distended  by  secretion  into  cysts  with  thin 
partition  walls   that  frequently  rupture,  so  that  many  small  cysts 


Pseudomucin   Cystadenomata 


467 


coalesce  into  larger  cyst  cavities.  In  the  thicker  walls  of  these 
cavities  the  proliferation  of  gland  tubules  progresses  rapidly  to 
form  new  daughter  cysts.  The  gland  tubules  in  ovarian  adeno- 
mata are  not  like  the  Pfliiger  tubes  or  egg  cords  in  the  formative 
stage  of  ovarian  development.  They  closely  resemble  the  tubu- 
lar utricular  glands. 

Ovarian  cystadenomata  are  divided  into  pseudomucin  cyst- 
adenomata  and  serous  cystadenomata,  according  to  their  contents 
and  the  character  of  their  epithelium. 

Pseudomucin  cystadenomata  are  probably  derived  from  the 


Fig.  417. — External  appearance  of  large  multilocular  ovarian  cyst  (35  pounds). 


follicular  epithelium.  They  are  the  commonest  kind  of  ovarian 
cyst. 

The  original  gland  tubules  in  which  the  growth  begins  soon 
disappear  on  account  of  the  rapid  accumulation  of  secretion  which 
quickly  distends  the  tubules  into  coalescing  cavities.  The  tubules 
and  cyst  cavities  are  lined  with  a  single  layer  of  high  columnar 
epithelium,  with  the  nucleus  at  the  base,  secreting  their  charac- 
teristic material  as  the  cells  of  the  stomach  and  gall-bladder 
secrete  their  mucus. 

The  pseudomucin  ^  (Hammarsten)  contained  in  these  cysts 
is  a  peculiar  substance  most  closely  resembling  mucus,  but  not 

1  Formerly  called  "  metalbumen." 


468  Diseases  of  the  Ovaries 

responding  to  its  acetic  acid  reaction.  It  has  no  chemical  resem- 
blance to  albumin  and  responds  to  none  of  the  agents  which 
coagulate  albumin.  After  boiling  with  the  mineral  acids  a  sort 
of  glucose  is  formed  which  gives  the  sugar  test  with  Fehling's 
fluid.  It  has  the  consistency  of  a  jellyfish  and  may  be  cut  with 
scissors.     It  is  perfectly  colorless  and  transparent. 

Typically  pure  pseudomucin  is  found  in  the  smaller  new- 
formed  cyst  cavities  of  a  cystadenoma.  In  the  larger  cavities 
there  is  a  serous  effusion,  often  some  blood  extravasation  and  cell 
detritus  which  gives  the  fluid  an  albuminous  character  and  alters 
its   color  to  white,  red,  black,  brown,  or  green,  and   changes  its 


Fig.  418. — Wall  of  glandular  cyst  of  ovary  :  cav,  Cavity  of  cyst ;  c  e,  columnar  epi- 
thelium ;  c  w,  fibrous  cyst- wall  (McConnell  and  J.  C.  Hirst). 


consistency  to   that   of   honey  or  water.      The  larger   the    cyst 
cavity,  the  less  resemblance  its  contents  have  to  pseudomucin. 

A  pseudomucin  cyst  is  always  multilocular,  but  one  cyst 
cavity  usually  predominates  in  size.  The  predominance  may 
be  so  great  that  the  cyst  appears  to  be  unilocular  until  it  is  care- 
fully studied.  On  the  other  hand,  there  may  be  no  great  difference 
in  the  size  of  the  cyst  spaces.  The  septa  between  the  cavities 
are  derived  from  the  main  enveloping  connective-tissue  tumor- 
wall.  They  carry  into  the  interior  of  the  tumor  the  blood-vessels 
which  enter  at  the  hilus  and  running  in  the  main  cyst- wall  send 
branches  along  its  continuation  in  the  partitions  between  the  cyst 


Pseudomucin   Cystadenomata 


469 


spaces.  The  tumor  is  usually  unilateral  and  pedunculate,  but 
it  may  be  bilateral  and  intraligamentary.  The  rate  of  growth 
varies,  but    is    comparatively  slow.      In  eight    or    nine    months 


Fig.  419. — Section  of  pseudomucin  cyst,  hardened  in  formalin  solution. 


Fig.   420. — Section  of  pseudomucin  cyst,  hardened  in  formalin  solution.      There  are 
numerous  loculi  of  about  equal  size. 


after  the  first  subjective  symptoms  the  tumor  is  commonly  as 
large  as  pregnancy  at  term.  In  the  older  literature  cases  are  re- 
corded in  which  ovarian  cysts  were  carried  for  many  years  and 
reached  an  enormous  size.      In  one  of  the  author's  patients  who 


470 


Diseases  of  the  Ovaries 


positively  refused  operation  it  took  eighteen  months  for  the  tumor 
to  grow  from  the  size  of  an  infant's  head  to  a  size  that  taxed  the 
capacity  of  the  abdominal  cavity  to  the  utmost,  and  to  a  weight 
of  more  than  90  pounds.  Pseudomucin  cysts  are  benign  and 
give  rise  to  no  recurrence  in  the  ordinary  pathological  sense,  but 
implantation  metastases  are  possible  in  the  visceral  and  parietal 
peritoneum  and  in  the  abdominal  wound  after  operations  for  their 
removal.  These  metastases  may  take  the  form  of  small  proliferat- 
ing cysts,  very  slow  in  growth  and  possibly  of  no  great  clinical  sig- 


Fig.  421. — Section   of  pseudomucin   cyst,  hardened  in  formalin   solution;  one  chief 
cyst  cavity,  occupying  about  half  the  bulk  of  the  tumor. 


nificance.  On  the  contraiy,  the  proliferation  of  the  epithelium 
and  the  production  of  pseudomucin  may  go  on  actively  and  un- 
checked until  enormous  tumors  develop  which  can  not  be  com- 
pletely removed  and  end  in  the  patient's  destruction.  In  the 
peritoneal  cavity  this  form  of  metastasis  is  known  as  psctido- 
myxoina  peritonei.  Fragments  of  cyst  epithelium  may  escape 
through  a  spontaneous  rupture  of  the  cyst-wall  or  during  an 
operation,  and  may  be  implanted  in  the  peiitoneum,  in  which  the 
same  sort  of  growth  continues  that  is  observed  in  the  parent  cyst. 
Masses  of  pseudomucin  weighing  40  pounds  have  been  removed 


Serous  Cystadenomata  of  the  Ovary  471 

from  the  peritoneal  cavity  (Olshausen).  The  operation  is  rarely 
complete  and  a  continuance  of  the  pseudomucin  formation  is  ob- 
served, requiring  perhaps  repeated  operations.  Abdominal  and 
fecal  fistulre  form  and  not  infrequently  the  patient  dies  of  exhaus- 
tion or  infection. 

Papillomatous  growths  in  pseudomucin  cysts  may  also  give 
rise  to  implantation  metastases.  Their  complete  removal  may  be 
impossible  and  the  ultimate  result  may  be  fatal  from  pressure 
upon  and  ulceration  of  the  pelvic  and  abdominal  viscera  or  from 
cancerous  degeneration  of  the  papilloma. 

Serous  cystadenomata  of  the  ovary  are  characterized  by  mul- 
tilocular  cysts  lined  with  a  columnar  ciliated  epithelium  and  con- 
taining a  yellowish  or  greenish  albuminous  fluid  without  colloid 
material  and  without  a  trace  of  pseudomucin.  There  is  reason  to 
believe  that  they  are  derived  from  the  superficial  or  germinal 
epithelium  of  the  ovary.  In  the  cyst-walls  there  are  the  same 
proliferating  gland  tubules  seen  in  pseudomucin  cysts.  The 
majority  of  serous  cystadenomata  are  papillay}'.  They  do  not 
as  a  rule  reach  a  very  large  size.  There  are  not  so  many  loculi  as 
in  pseudomucin  cysts  and  many  of  the  tumors  appear  macroscop- 
ically  to  be  unilocular,  the  septa  between  the  large  cyst  spaces 
having  ruptured  or  undergone  necrosis.  The  non-papillary  cysts 
are  usually  pedunculated.  The  papillomatous  cysts  are  com- 
monly intraligamentary  and  subserous. 

The  non-papillary  cysts  are  very  slow  of  growth,  are  usually 
unilateral,  occasion  little  disturbance,  are  not  a  cause  of  ascites, 
and,  having  a  good  pedicle,  are  easily  removed.  They  do  not 
recur  and  scarcely  ever  give  rise  to  implantation  metastases.  The 
papillary  serous  cystadenomata  are  also  slow  in  growth,  but, 
being  intraligamentary,  as  a  rule  cause  serious  pressure  symp- 
toms, and  the  luxuriant  growth  of  papillomata  both  in  the  inte- 
rior and  on  the  surface  of  the  tumor  often  gives  rise  to  peritoneal 
implantation  metastases  (13.3  per  cent. — Pfannenstiel).  It  may 
be  impossible  to  remove  all  the  papillary  masses  or  a  small  por- 
tion of  the  papillary  growth  may  be  inadvertently  set  free  in  the 
peritoneal  cavity  during  an  operation.  Recurrence  of  the  growth 
in  such  cases  is  likely,  with  involvement  of  vital  organs.  Ascites, 
often  to  an  enormous  extent,  is  the  invariable  rule  in  superficial 
papillomata;  it  is  usually  associated  with  pleural  effusion.  These 
growths  are  often  bilateral.  Even  if  one  ovary  appears  healthy 
at  the  time  of  operation,  the  development  in  it  of  a  papillary 
serous  cystadenoma  is  likely  in  the  future.  Both  ovaries,  there- 
fore, should  be  removed  even  if  only  one  is  affected.  Every 
particle  of  the  papillomatous  growth  should  also  be  removed 
wherever  situated,  else  a  recurrence  may  be  expected. 


472 


Diseases  of  the  Ovaries 


Papillomatous  Growths  in  Ovarian  Cysts. — As  already  stated, 
papillomata  may  develop  in  any  ovarian  cystic  neoplasm,  in 
simple  serous  cysts,  pseudomucin  cysts,  and  serous  cystadeno- 
mata.  They  are  most  frequently  seen  in  the  last  named.  The 
growth  is  a  proliferation  of  epithelium  analogous  to  the  prolifer- 
ating gland  tubules  of  the  cystadenoma,  but  growing  outward 
instead  of  inward.  The  histology  is  that  of  benign  columnar 
cell  papilloma  everywhere.  There  is  a  branched  extension  of 
epithelium  in  a  single  layer,  with  a  basis  of  connective  tissue 
which  in  the  older  parts  of  the  growth  constitutes  a  stem  of  con- 
siderable thickness.      The  whole  mass  may  be  cauliflower  in  form, 


Fig.  422. — Papilloma  removed  from  posterior  surfaces  of  broad  ligaments  and  uterus. 


with  a  pedicle,  but  the  latter  may  be  very  short  or  altogether 
wanting.  The  growth  may  be  elevated  to  the  size  of  an  apple 
or  larger,  or  may  be  small  excrescences  giving  the  surface  from 
which  they  grow  the  rough  appearance  of  a  file.  The  growth  is 
very  vascular.  It  is  prone  to  degenerative  changes,  fatty  de- 
generation, necrosis,  and  calcification.  Myxomatous  degener- 
ation of  the  end-branches  of  the  papillae  is  occasionally  observed, 
distending  them  into. knob-like  proces.ses  like  the  chorion  villi  in 
cystic  degeneration,  and  giving  to  the  tumor  the  grape-like  form 
of  a  hydatidiform  mole.  While  papillary  growths  are  usually 
found  in  the  interior  of  the  ovarian  c)'sts,  they  are  not  infrequently 
developed   on   the   surface,  especially  in   serous   cystadenomata. 


Papillomatous   Growths  in   Ovarian   Cysts       473 

Ascites  alwa\'s  follows  and  the  growth  usually  spreads  over  the 
pelvic  peritoneum  or  is  implanted  anywhere  on  peritoneal  surfaces. 
The  explanation  of  surface  papillomata  is  usually  a  growth  of  the 
surface  germinal  epithelium  of  the  ovary  and  not  a  rupture  or 
perforation  of  the  cyst-wall,  setting  free  the  papilloma  of  the  in- 
terior, though  such  an  occurrence  is  possible.  Rarely  the  papil- 
lomata may  undergo  cancerous  degeneration.  Without  any  such 
malignant  change  they  themselves  are  on  the  border-line  between 
benign  and  malignant  growths.  While  they  do  not  actually 
invade  the  tissues  and  structures  to  the  peritoneal  covering  of 
which  they  are  attached,  their  tendency  to  spread,  to  implantation 


Fig.  423. — Part  of  wall  of  papillary  ovarian  cyst :   cav.,  Cyst  cavity  ;  /,  papillae 
(McConnell  and  J.  C.  Hirst). 


metastases,  and  to  recurrence  gives  them  a  semi-malignant 
character.  They  complicate,  often  gravely,  the  operative  treat- 
ment of  ovarian  cysts.  The  removal  of  an  intraligamentary 
papillomatous  serous  cystadenoma  is  usually  a  formidable  task 
and  its  complete  removal  may  prove  impracticable.  It  may  also 
be  difficult  or  impossible  to  remove  the  papillomatous  masses 
from  peritoneal  surfaces  in  superficial  growths.  A  papilloma- 
tous growth  in  an  ovarian  cyst  must  therefore  be  regarded  as  an 
unfavorable  complication. 

If,  however,   the   complete   eradication    of   the    papilloma    is 
practicable,  as  is   usually  the  case,  the  result  of  operative  treat- 


474  Diseases  of  the  Ov^aries 

ment  is   satisfacton'.      The   ascites   and   pleural   effusion  perma- 
nently disappear  and  there  is  no  recurrence  of  the  growth. 

Ovulogenous  Ovarian  Tumors  ;  Dermoids  and  Teratomata. 
— The  Ovulogenous  Neoplasms. — Dermoids  ^  of  the  ovary  differ 
from  dermoids  of  other  parts  of  the  body.  There  is  a  spherical 
ovarian  tumor  with  a  firm  white  capsule,  usually  moderate  in  size, 
filled  with  fatty  or  so-called  sebaceous  matter  and  hair,  but  having 
on  one  part  of  its  otherwise  smooth  internal  wall  an  elevation  or 
thickening  of  varying  size  which  is  an  imperfect  embryo,  with  all 
three  of  the  blastodermic  membranes  represented,  the  ectoderm 
showing  the  greatest  development,  the  mesoderm  the  next,  and 


Fig.  424. — Malignant  degeneration  of  papillary  ovarian  cyst  (McConnell  and  J.  C. 

Hirst). 


the  entoderm  the  least.  The  cephalic  region  is  commonly  much 
more  advanced  in  growth  than  the  other  embryonal  structures, 
so  that  besides  the  hair  and  fluid  fatty  matter,  jaw-bones  and 
teeth  are  the  most  easily  recognizable  fetal  parts.  The  hair, 
which  often  fills  the  tumor  in  a  tangled  mass,  but  is  sometimes 
present  in  tresses  more  than  three  feet  long,  always  grows  from 
one  portion  of  the  embryonal  region,  representing  the  scalp.  ^  It 
is   usually   of    a   reddish    color,    but   may   be    black    or    brown. 

^  "  Embryomata  "  would  be  a  more  appropriate  and  accurate  name  for  these 
tumors. 

2  In  one  reported  case  there  was  a  growth  of  hair  at  the  scalp  and  at  the  mons 
veneris. 


Dermoid  Cysts 


475 


Directly  beneath  this  region,  on  section,  possibly  with  some 
plates  of  bone  intervening,  is  found  a  substance  representing  the 
brain.  Next  to  it  are  the  structures  representing  the  jaw-bones, 
usually  in  miniature,  but  sometimes  of  natural  size.^  From 
this  region  the  teeth  grow,  in  some  cases  in  astounding  num- 
bers. More  than  300  have  been  found  in  one  specimen.  The 
rest  of  the  embryonal  region  is  commonly  a  confused  jum- 
ble of  muscle  fragments,  cartilage,  and  structures  lined  with 
columnar  epithelium  representing  the  entoderm.  Rarely  there 
may  be  a  more  perfect  development  of  the  fetal  body  or  of  certain 
parts  of  it.  There  have  been  found  ribs,  pelvic  bones,  jointed 
long   bones,  fingers,  hands  or  their  rudiments,  lower  extremities, 


Fig.  425.— Section  of  an  ovarian  dermoid  or  embryoma. 


thyroid,  submaxillary  and  mammary  glands,  some  of  them 
secreting  colostrum  and  one  of  them  undergoing  cancerous  de- 
generation. ^  In  a  specimen  removed  in  the  Howard  Hospital 
there  was  a  well-developed  eye.  Regnier's  case  had  a  complete 
skeleton,  perfect  on  the  right  side  to  the  phalanges.^ 

Dermoids  may  be  multiple;  five  and  seven  have  been  found  in 
one  tumor.  It  is  not  very  unusual  to  find  dermoids  in  both 
ovaries,  though  in  the  author's  experience  this  is  a  much  rarer 

1  In  one  of  my  specimens  in  the  Howard  Hospital  there  is  a  perfect  half  of  a 
lower  jaw  in  miniature  with  the  incisor  and  canine  teeth,  in  a  dermoid  tumor  no  larger 
than  a  crab-apple. 

2  Yamagiva,  "Virchow's  Archiv,"  Bd.  cxlvii,  H.  I. 
^  Pfannenstiel,  Veit's  "  flandbuch,"  vol.  iii,  p.  370. 


476 


Diseases  of  the  Ovaries 


occurrence  than  most  statistics  indicate.      (Olshausen  found  it  in 
^2)  per  cent.) 

A  dermoid  cyst  is  usually  combined  with  a  simple  serous 
cyst  or  a  pseudomucin  cyst  of  the  ovary.  In  the  latter  case  the 
embryonal  area  is  attached  to  the  wall  of  the  main  cyst  cavity.  The 
fluid  contents  of  the  cyst  are  composed  mainly  of  fat,  desqua- 
mated epidermis  cells,  cell  detritus,  and  occasionally  cholesterin 
crystals.  At  the  temperature  of  the  body  the  mixture  is  fluid  ; 
at  a  lower  temperature  it  coagulates  to   a  cheesy  consistency. 


Fig.  426. — Section  of  a  pseudomucin  cyst  and  an  associated  dermoid  or  embryoma  in 

its  interior. 


Fat  globules  the  size  of  a  cherry  have  been  found  floating  in  a 
thinner  fluid.  They  are  formed  by  concentric  layers  of  fat  de- 
posited around  a  kernel  of  cholesterin. 

Frequency. — According  to  Pfannenstiel,  7.5  per  cent,  of  all 
ovarian  tumors  contain  a  dermoid.  But  the  proportion  is  consid- 
erably smaller  if  one  counts  as  dermoid  cysts  only  the  tumors  in 
which  the  dermoid  is  a  predominant  feature. 

Clinical  History. — Dermoids  may  be  found  at  any  age,  but 
they  are  most  frequently  discovered  during  the  period  of  sexual 


Dermoid   Cysts  477 

activity,  from  pubert}-  to  the  menopause.  They  are  exceedingly- 
slow  in  growth,  and  may  be  contained  in  the  abdomen  twent}' 
years  or  more.  They  may  remain  stationary  in  size  for  indefinite 
periods,  giving  rise  to  no  symptoms.  From  the  length  of  time 
that  they  are  carried  in  the  abdominal  cavity  they  are  exposed  to 
the  complications  common  to  all  ovarian  tumors  :  twisted  pedicle, 
necrosis,  gangrene,  rupture  and  injury  in  labor.  In  consequence 
of  their  moderate  size,  spherical  outline,  and  pedunculated  form 
they  are  liable  to  become  impacted  in  the  pelvis  and  to  give  rise 
to  pressure  symptoms.    They  appear  to  respond  more  rapidly  to 


Fig.  427. — Dermoid  cyst  of  ovary,  showing  squamous  epithelium,  hair  follicles, 
sebaceous  gland,  and  bone  :  s,  Squamous  epithelium  ;  s.zci,  sebaceous  glands  ;  d,  plates 
of  bone;  /i,  hair  follicles;  i-.w,  cyst-wall;  ca?',  cyst  cavity  (McConnell  and  J,  C. 
Hirst). 

the  stimulus  of  pregnancy  to  growth  than  the  other  ovarian  cysts, 
and  it  is  not  unlikeh-  that  pregnancy  may  rarely  be  the  starting- 
point  of  a  parthenogenetic  development  in  the  ovary.  The  pro- 
portion of  dermoid  cysts  complicating  gestation  is  larger  than  it 
should  be,  considering  their  proportion  to  other  ovarian  tumors.^ 
Rupture  of  a  dermoid  cyst  and  the  setting  free  of  the  dirty-look- 
ing and  putrescible  contents  into  the  peritoneal  cavity  have  been 
regarded  with  anxiety.  The  contents  of  the  cyst  are,  however, 
sterile,  and  if   evacuated   during  an   operation   and   immediately 

1  In  eight  operations  for  ovarian  cysts  complicating  the  child-bearing  process  I 
have  found  dermoids  three  times. 


478 


Diseases  of  the  Ovaries 


cleaned  out  should  not  cause  inflammatory  trouble.  If  some 
time  elapses  between  the  rupture  and  the  abdominal  section,  the 
results  may  be  more  serious.  The  patient  may  die  of  a  putre- 
factive peritonitis  after  the  abdomen  is  opened,  or  the  cyst  con- 
tents may  be  encapsulated  in  numerous  areas  over  the  perito- 
neum, giving  the  appearance  of  implantation  metastases,  and 
single  hairs  may  be  caught  in  the  peritoneal  exudate  by  their  ends, 
making  them  look  as  though  they  grew  from  the  peritoneum. ^ 

A  dermoid  cyst  is  a  benign  growth.     It  may  in  rare  instances 
be   associated  with   malignant   tumors   of  the   ovary  and   it  may 


Fig.  428.- 


-  Dermoid  tumor  of  ovary  with  a  well-developed  eye 
in  the  embryonal  area  (Howard  Hospital). 


a,  Well-formed  eye 


itself  very  rarely  undergo  malignant  degeneration.  In  addition 
to  Yamagiva's  remarkable  case  of  mammary  cancer  in  a  dermoid, 
ten  cases  of  squamous-cell  cancer,  originating  in  the  embryonal 
area,  have  been  collected  by  Wilms  and  Pfannenstiel. 

Etiology. — The   only  satisfactory  explanation   of   a   dermoid 

^  In  one  of  my  cases  a  very  large  cyst  was  ruptured  while  the  abdomen  was 
being  scrubbed  the  day  before  the  operation.  On  the  following  day  the  abdominal 
cavity  was  found  full  of  the  sebaceous  contents  that  clung  so  tightly  to  all  the  perito- 
neal surfaces  by  adhesive  inflammation  that  it  was  absolutely  impossible  to  wash  or 
wipe  it  away.  After  a  prolonged  effort  to  cleanse  the  abdomen  it  was  closed  with  a 
large  amount  of  the  cyst  contents  remaining  in  it.  The  patient  died  within  twenty 
hours  of  a  putrefactive  peritonitis. 


Carcinoma  of  the  Ovary  479 

tumor  in  the  ovary  is  a  parthenogenetic  development  from  an  ovule 
which  is  stimulated  to  growth  perhaps  by  some  other  tumor  for- 
mation such  as  a  simple  serous  cyst  or  a  pseudomucin  cyst.  As 
both  these  tumors  are  derived  from  the  follicular  epithelium  the 
stimulus  their  growth  would  impart  to  one  or  more  ovules  in  the 
follicles  is  evident.  What  determines  the  growth  of  the  ovule  in 
some  instances  and  not  in  others  is  still  a  mystery. 

Teratomata  of  the  ovary  are  very  rare.  According  to  Kromer, 
there  are  only  ten  recorded  cases.  ^  They  have  the  same  histo- 
genesis as  ovarian  dermoids,  but  clinicalU-  they  differ  consider- 
ably. They  are  solid  tumors,  reach  an  enormous  size,  are  some- 
times pedunculated,  sometimes  intraligamentary.  The  capsule  is 
smooth,  composed  of  connective-tissue  layers,  containing  histo- 
logical traces  of  ovarian  structure.  Internally  the  tumor  is 
divided  by  fibrous  trabeculae  into  small  spaces  which  contain 
young  connective  tissue,  of  a  brain-like  consistency,  reddish-gray 
in  color,  extremely  prone  to  sarcomatous  degeneration,  if  not 
always  sarcomatous.  Small  cysts  are  scattered  through  the 
tumor.  The  embryonal  structures  are  intermingled  and  con- 
fused in  the  most  extraordinary  manner.  All  three  blastodermic 
membranes  are  represented,  but  the  structures  derived  from  them 
are  scattered  through  the  tumor  without  the  least  trace  of  orderly 
arrangement ;  bits  of  cartilage,  nervous  tissue,  muscle,  fat,  and 
bone  may  be  found  jumbled  together. 

The  ovarian  teratomata  are  clinically  malignant  growths,  of 
the  sarcoma  group. 2 

Carcinoma  of  the  ovary  may  be  primaiy  or  metastatic,  or  it  may 
be  due  to  a  carcinomatous  degeneration  of  an  adenoma  or  dermoid. 
The  first  named  is  the  most  frequent.  It  is  usually  a  medullary 
cancer  diffusely  infiltrating  the  ovary,  but  may  be  scirrhous.  The 
tumor  may  be  solid,  is  usually  spherical  in  shape  and  peduncu- 
lated. The  cystic  cancers  are  a  commoner  form  than  the  solid. 
They  are  multilocular,  the  cyst  spaces  containing  a  serous  fluid, 
which  may  resemble  pus  on  account  of  the  desquamation  of 
epithelial  cells,  or  may  be  mixed  with  blood.  According  to 
Pfannenstiel,  the  cystic  cancers  are  as  a  rule  papillary,  and  almost 
half  of  all  papillary  ovarian  tumors  are  adenocarcinomata.  On 
section  the  tumor  in  its  solid  portions  has  a  brain-like  con- 
sistency very  different  from  anything  seen  in  the  cystadenomata. 

Adenocarcinoma  may  be  secondary  to  the  same  growth  in 
the  uterus   or  the  bowel.      So-called  colloid   cancers  are  usually 

^  Jung  reports  two  additional  cases  ("  jNIonatsschr.  f.  Geburtsh.  u.  Gyn.,"  Bd. 
xiv,  p.  646). 

2  Jung  and  others  question  the  invariable  malignancy  of  these  growths,  but  ac- 
knowledge the  tendency  to  malignant  degeneration  [loc.  ci'L). 


4So 


Diseases  of  the  Ovaries 


pseudonuicin  c\-sts  with  very  small  and  numerous  loculi,  but  there 
is  a  form  of  carcinoma  in  which  the  epithelium  penetrates  the 
connective  tissue  in  proliferating  nests,  resembling  the  macro- 
scopic appearance  of  a  pseudomucin  cyst. 

Cancer  of  the  ovary  is  commonest  in  elderly  or  middle-aged 
women,  but  it  occurs  at  the  time  of  puberty  and  in  childhood. 
It  is  usually  bilateral.  The  rate  of  growth  is  rapid  except  in  the 
scirrhous  form.  There  is  almost  always  ascites  unless  the  growth 
is  intraligamentary.  Edema  of  the  thighs  is  the  rule,  and  swell- 
ing of  the  inguinal  glands  is  not  uncommonly  observed.  The 
general  health  may  be  well  preserved  for  a  considerable  time,  but 


Fig.  429. — Malignant  adenoma  of  ovary  :   n-.s.  Gland-spaces,  communicating  and  lined 
with  hyperplastic  columnar  epithelium  (McConnell  and  J.  C.  Hirst). 


cachexia  at  length  appears.  Pain  is  a  variable  symptom.  In 
most  patients  it  appears  early  and  is  intense.  It  may  be  entirely 
absent  Constipation  and  tympany  are  usually  marked.  The 
diagnosis  is  always  difficult  to  make.  Many  cases  of  ovarian  can- 
cer give  the  impression  of  a  uterine  fibroid.  As  the  size  of  the 
growth  is  moderate,  an  immediate  operation  is  frequently  not 
advised.  By  the  time  that  the  condition  admits  of  a  diagnosis, 
the  operative  treatment  is  usually  hopeless.  Under  all  circum- 
stances the  prognosis  is  unfavorable.  There  is  a  recurrence  in 
three -fourths  to  four-fifths  of  the  cases.  Both  ovaries  should 
always  be  removed,  even  though  one  is  apparently  healthy. 


Stromatogenous  Neoplasms 


481 


Stromatogenous    Neoplasms. — Fibromata    of  the  ovary   are 

characterized  by  a  diffuse  growth  of  the  connective-tissue  ele- 
ments often  containing  unstriped  muscle- fibers  converting  the 
ovary  into  a  fibromyomatous  tumor,  with  a  disappearance  in 
great  part  of  the  parenchyma.  The  growth  is  moderate  in  size, 
somewhat  irregular  in  outline,  white  in  color,  hard  in  feel,  and 
heavy.  It  is  occasionally  bilateral  and  may  be  associated  with 
uterine  fibroids.  It  is  usually  pedunculated,  but  may  be  intra- 
ligamentary.      The    rate    of  growth    is    extremely    slow.      The 


Fig.  430. — Fibroma  of  the  ovary. 


tumor  gives  rise  to  few  symptoms  and  may  be  carried  for  a  life- 
time by  the  patient  without  much  inconvenience.  It  occurs  at 
any  time  of  life  from  infancy  to  advanced  old  age.  The  most 
curious  clinical  feature  of  ovarian  fibromata  is  the  frequency  of 
ascites,  which  has  been  variously  explained  by  a  mechanical  irri- 
tation of  the  peritoneum,  a  congestion  of  the  broad  ligament,  and 
a  chemical  irritation  of  the  peritoneum  by  secretions  from  the 
tumor. 

Fibromata  of  the  ovary  are  entirely  benign.      They  do  not 


4S2  Diseases  of  the   Ovaries 

recur.  The  ascites  which  the)'  cause  disappears  after  their  re- 
moval. The}-  are  subject  to  all  the  degenerations  of  a  fibroid 
tumor  and  to  the  accidents  of  an  ovarian  tumor  (twisted  pedicle, 
displacements,  incarceration  in  the  pelvi.s).  They  constitute 
about  2  per  cent,  of  all  ovarian  tumors. 

Rokitansky  describes  a  fibroma  of  the  corpus  luteum  with  a 
fibrous  core  the  size  of  a  walnut  surrounded  by  a  membrane 
which  may  present  the  typical  folds  of  a  lutein  membrane. 

Sarcomata  and  Endotheliomata  of  the  Ovary. — The  ovarian  sar- 
comata are  spindle,  round-celled,  or  mixed.  The  first-named  re- 
semble fibromata.      There  is  a  fibrosarcoma  which  is  difficult  to 


Fig.  431. — Fibroma  of  ovary  (McConnell  and  J.  C.  Hirst). 

differentiate  from  a  fibroma  and  which  is  scarcely  malignant. 
The  round-cell  sarcomata  are  soft  in  consistency,  rapid  in  growth, 
and  resemble  macroscopically  medullary  cancers  of  the  ovary. 
Degenerative  changes  occur  early  and  to  a  marked  degree.  The 
ovarian  parenchyma  is  soon  destroyed. 

The  endotheliomata  of  the  ovary,  derived  from  the  lymphatic 
and  vascular  endothelium,  are  an  intermediate  form  of  growth 
between  the  cancers  and  the  sarcomata.  According  to  Pick,  they 
assume  three  forms :  circumscribed  collections  of  chains  of  cells, 
tubular  gland-like  formation  of  cells,  and  a  distinct  sarcomatous 
type  with  a  slight  indication  of  alveoli.  Sarcoma  of  the  ovary 
develops  at  any  time  of  life,   but  is    most   frequent   in   women 


Sarcomata  and  Endotheliomata  of  the  Ovary     483 

slightly  uiuler  middle  age.  The  younger  the  patient,  the  moi-e 
likel}'  is  the  growth  to  be  a  round-cell  sarcoma.  The  tumor  is 
frequently  bilateral  and  is  usually  associated  with  ascites.  It  is 
not  quite  so  malignant  as  cancer  of  the  ovary.  Permanent  cures 
by  operation  have  been  obtained  in  50  to  75  per  cent,  of  the 
cases.  According  to  Pfannenstiel's  statistics,  sarcomata  constitute 
5  per  cent,  of  ovarian  tumors. 

Aiigioinata  of  the  ovary  have  been  described.  ^  Enchondroniata 
and  ostcomata  occasionally  reported  are  no  doubt  teratomata. 
Pick  2  has  described  a  tumor  of  the  hilus  of  tlie  ovary  derived  from 


Fig.  432. — Sarcoma  of  both  ovaries,  removed  from  a  child  of  seven  years. 


Marchand's  accessory  suprarenal  bodies,  with  a  malignant  ten- 
dency;  Gottschalk,^  a  malignant  tumor  springing  from  the  fol- 
licular epithelium,  /^i/Z/r?//^;;/*^  maligmim.  A  combination  of  some 
of  the  ovarian  tumors  described  above  may  be  observed,  as  of 
dermoids  and  pseudomucin  or  simple  serous  cysts,  cystadenomata 
and  sarcomata,  or  carcinomata,  etc.  A  serous  cystadenoma  is 
almost  never  associated  with  a  dermoid  or  a  pseudomucin  cyst 
on  account  of  the  origin  of  the  one  from  the  surface  germinal 
epithelium,  and  of  the  others  from  the  follicular  epithelium 


1  Veit's  "  Handbuch  der  Gyn., 
~  "Arch.  f.  Gyn.,"  Bd.  Ixiv. 


vol.  iii,  p.  403. 


3  Ibid. ,  Bd.  lix. 


484 


Diseases  of  the  Ovaries 


Parovarian  Cysts. — It  is  convenient  to  describe  cysts  of  the 
parovarium  in  the  section  on  ovarian  tumors,  with  which  they 
have  much  in  common  in  chnical  history,  symptoms,  and  treat- 
ment. 

Parovarian  cysts  are  derived  from  the  parovarium,  or  in  excep- 
tional cases  perhaps  from  an  accessory  tube.  They  constitute 
from  9  to  1 1  per  cent,  of  the  cystic  tumors  of  the  ovary  and 
broad  h'gament.  They  occur  most  commonly  from  the  thirtieth 
to  the  fiftieth  year  or  at  puberty.  They  are  usually  unilocular, 
though  not  invariably  so  ;  their  capsule  is  a  thin,  flaccid,  con- 


Fig.  433. — Large  parovarian  cyst,  pedunculated. 


nective-tissue  structure,  over  which  the  peritoneum  of  the  broad 
ligament  is  freely  movable.  The  tube  runs  over  and  behind  the 
tumor,  being  sometimes  lengthened  to  40  centimeters  or  more,  with 
an  ovarian  fimbria  measuring  as  much  as  10  centimeters  in  length. 
The  ovary  is  occasionally  merged  in  the  wall  of  the  tumor  and 
drawn  out  to  an  extreme  length,  but  usually  it  is  quite  indepen- 
dent of  the  growth.  The  tumor  cavity  is  lined  with  a  single  layer 
of  columnar  ciliated  epithelium,  which  is  occasionally  degenerated 
and  flattened  by  intracystic  pressure  or  deprivation  of  blood-sup- 
ply. The  blood-vessels  run  in  the  tumor-wall  and  are  entirely 
distinct  from  those  of  the  broad  lig-ament.      The  contents  of  the 


Parovarian   Cysts  485 

cyst  are  a  clear  liquid,  almost  colorless,  slightly  opalescent,  of 
low  specific  gravity,  containing  neither  mucin  nor  albumin.  In 
large  parovarian  cysts  the  color  of  the  fluid  and  its  density  may 
be  altered  by  degenerative  processes  or  hemorrhagic  effusions. 

The  growth  is  necessarily  intraligamentary,  but  large  tumors 
are  usually  pedunculated,  the  pedicle  consisting  of  the  tube, 
broad  ligament,  and  the  ovarian  ligaments. 

The  tumor- walls  are  so  flaccid  that  the  form  of  the  tumor 
varies  remarkably  in  different  postures.  The  shape  of  the  abdo- 
men in  the  supine  position  suggests  ascites,  but  there  is  resonance 
in  the  flanks.      Fluctuation  is  distinct  on  percussion. 


Fig.   434. — Cyst    of   the    parovarium :   cont^    Cyst   contents ;  c  w,  cyst- wall ;  v,  villi 
(McConnell  and  J.  C.  Hirst). 

Parovarian .  cysts  are  usually  moderate  in  size  and  slow  in 
growth,  but  they  may  be  enormous.  The  author  has  removed 
two  which  taxed  the  capacity  of  the  abdomen  to  the  utmost.  They 
give  rise  to  very  few  symptoms  and  to  little  inconvenience  unless 
they  attain  a  large  size.  They  are  absolutely  benign,  not  re- 
curring when  removed.  Rupture  frequently  occurs  on  account 
of  the  tenuity  of  the  walls.  Sometimes  a  spontaneous  cure  oc- 
curs in  this  way,  but  the  cyst  usually  refills  slowly.  Ordi- 
narily the  tumor  is  unilateral,  but  both  broad  ligaments  may 
exceptionally  be  affected.  Papillomatous  outgrowths  have  been 
observed   in   parovarian  cysts,   but   they  are  usually  fibrous  in 


486  Diseases  of  the   Ovaries 

character  and  not  luxuriant  in  growth.  The  unilocular  thin- 
walled  cyst  is  almost  the  only  tumor  of  the  parovarium,  but  the 
following  neoplasms  of  this  structure  have  been  reported  :  papil- 
lary cystadenoma,  carcinoma,  adenosarcoma,  multicystic  ade- 
noma, fibro-adenoma,  and  fibrosarcoma  (Pfannenstiel). 

Clinical  History  of  Ovarian  Tumors. — There  is  often  a  com- 
plete absence  of  s)-mptoms  until  the  ovarian  cyst  reaches  such  a 
size  as  to  attract  attention  by  the  distention  of  the  abdomen.  There 
are  usuall}-  none  of  the  local  pains  or  reflex  symptoms  so  com- 
mon to  other  forms  of  ovarian  disease,  except  that  there  is  not 
infrequently  an  excitation  of  the  breasts  and  colostrum  secre- 
tion. Pressure  symptoms  of  the  bladder  and  bowel  may,  how- 
ever, appear  early,  and  are  most  severe  in  intraligamentary 
growths.  Pain  is  almost  entirely  absent  unless  the  growth  is 
malignant,  or  there  are  pressure  symptoms,  twisted  pedicle,  nec- 
rosis or  infection  of  the  tumor.  Ascites  is  associated  with  ma- 
lignant growths,  fibromata,  and  papillomata,  and  may  be  the  chief 
cause  of  complaint.  If  it  is  exaggerated  there  is  usually  an  as- 
sociated pleural  effusion  and  embarrassed  respiration.  Most  often 
in  consequence  of  ascites,  sometimes  without,  there  may  be  a 
prolapse  of  the  uterus  or  vagina  in  women  predisposed  to  that  dis- 
placement, due  to  the  increased  intra-abdominal  pressure.  The 
menstruation  is  often  quite  unaffected.  It  is  not  infrequently  scanty, 
irregular,  or  suppressed.  The  coincidence  of  suppressed  menstru- 
ation and  an  abdominal  tumor  has  often  given  rise  to  the  mis- 
taken diagnosis  of  pregnancy. 

In  tumors  that  destroy  both  ovaries,  as  bilateral  malignant 
growths,  there  is  usually  amenorrhea.  In  intraligamentary  papil- 
lomatous growths,  on  the  contrary,  menorrhagia  is  the  rule. 

The  duration  of  an  ovarian  growth  \'aries  greatly  with  its 
nature,  and  is  variable  in  individual  varieties.  Round-cell  sar- 
comata in  young  people  grow  with  the  greatest  rapidity.  Car- 
cinomata  are  usually  quite  rapid  in  growth.  Fibromata  and  fibro- 
sarcomata  are  exceedingly  slow  in  development.  The  glandular 
cysts  vary  greatly  in  individual  instances  in  their  rate  of  growth. 
In  the  older  literature  cases  are  recorded  often,  fifteen,  and  even 
fifty  years'  duration.  On  the  average,  according  to  Olshausen, 
60  to  70  per  cent,  of  women  with  glandular  cysts  die  within 
three  years  and  another  Jo  per  cent,  in  the  fourth  year. 

One  scarcely  ever  sees  at  present  the  enormous  cysts  that 
were  common  in  a  former  generation.  It  is  rare,  therefore,  to 
observe  the  emaciation,  the  pressure  symptoms  on  abdominal  and 
thoracic  contents,  the  enormous  distention  of  the  abdominal  wall, 
with  the  enlarged  veins  and  stride  under  the  skin  that  are  asso- 
ciated with  tumors   of  the  largest  size.      All  ovarian  tumors,  but 


Twisted   Pedicle  487 

most  particularly  the  glandular  and  dermoid  cysts,  are  liable  to 
the  complications  of  twisted  pedicle,  rupture,  inflammation  and 
suppuration. 

Twisted  Pedicle. — As  already  stated,  an  ovarian  tumor  is 
usually  twisted  on  its  pedicle  by  90  degrees  in  the  course  of  its 
normal  migration,  during  its  growth,  from  the  pelvis  to  the  abdo- 
men. The  movement  is  almost  always  from  within,  outward  and 
forward,  so  that  a  right-sided  tumor  would  turn  to  the  right  and 
forward,  a  left  to  the  left  and  forward.  This  movement  makes  of 
the  pedicle  a  left  spiral  on  the  right  side,  a  right  spiral  on  the  left 
side.  In  consequence  of  the  pressure  of  intestines  to  one  side 
of  and  behind  the  growth,  sudden  movements,  relaxed  abdominal 
walls,  especially  after  childbirth,  gynecological  examinations,  or 
other  causes  not  clearly  understood,  the  tumor,  especially  if 
it  is  moderate  in  size,  with  a  spherical  shape  and  smooth 
walls,  may  be  twisted  on  its  pedicle  by  one-half  to  seven 
complete  turns.  The  result  is  a  more  or  less  complete  strangu- 
lation of  the  growth  :  its  walls  are  bluish-black  in  color,  there 
is  a  sudden  increase  in  size,  a  consequent  tension  of  the  walls 
which  may  rupture,  and  an  intracystic  effusion  of  blood,  which, 
if  the  w'alls  rupture,  may  become  intraperitoneal  and  may 
prove  fatal.  If  the  arterial  supply  is  completely  cut  off,  necrosis 
of  the  tumor  necessarily  follows.  The  pedicle  has  been  completely 
severed  by  torsion  and  the  tumor  has  been  set  free  in  the  abdominal 
cavity,  contracting  adhesions  to  the  omentum  and  bowels  and  de- 
riving nutriment  from  their  blood-vessels.  In  any  event  from  the 
destruction  of  the  surface  epithelium,  extensive  adhesions  are  likely 
to  form  between  the  tumor-wall  and  neighboring  structures. 

Thrombosis  of  the  veins  in  the  broad  ligament  is  not  uncom- 
mon and  may  be  so  extensive  as  to  be  a  serious  source  of  em- 
barrassment in  placing  the  ligature  around  the  pedicle.  It  may 
be  necessary  to  include  a  large  thrombotic  vein,  as  in  one  of  the 
author's  cases,  and  pulmonary  embolism  may  be  the  result. 

Tlie  symptoms  of  twisted  pedicle  are  peritonitis,  high  tempera- 
ture, rapid  pulse,  and  in  case  of  profuse  intracystic  or  intra- 
abdominal bleeding,  shock  and  collapse.  The  peritonitis  is  not  in- 
fectious, as  the  abdominal  contents  are  sterile.  In  the  presence  of 
these  symptoms  and  with  the  physical  signs  of  an  abdominal  or 
pelvic  tumor  the  diagnosis  is  easily  made.  Hemoglobinuria  has 
been  observed.  ^ 

The  treatment  is  the  removal  of  the  tumor  as  soon  as  prac- 
ticable. The  adhesions  which  are  early  formed  are  light  and 
easily  broken  ;  later,  when  they  are  better  organized,  they  are 
extremely  dense  and  firm.   While  the  peritonitis  is  not  at  first  in- 

^  Kober,  "  Deutsche  med.  Wochenschrift,"  1901,  p.  13 1. 


4S8  Diseases  of  the  Ovaries 

fectious,  micro-organisms  ma\-  find  their  way  to  the  partially  or 
wholly  necrotic  tumor  from  the  bowels  or  tubes,  and  it  may 
become  gangrenous.  Even  if  the  patient  survive  the  primary 
s}-mptoms  of  the  twisted  pedicle,  she  is  Hkely  to  be  bedridden 
for  a  long  time  while  absorbing  the  necrotic  portions  of  the 
tumor,  and  she  may  at  any  time  become  septic.  Nothing  is 
gained,  therefore,  by  delay,  and  the  results  of  immediate 
operations  are  usually  very  satisfactory.  Before  ligating  the 
pedicle,  it  should  be  untwisted.  Unusual  care  should  be  exercised 
in  handling  the  growth  so  as  not  to  rupture  its  walls  and  to  set  free 
in  the  abdominal  cavity  the  bloody  putrescible  contents  ;  but  if 
to  diminish  its  size,  or  accidentally  the  wall  is  punctured,  the 
toilet  of  the  peritoneum  should  be  carefully  made. 

Rupture. — In  consequence  of  a  blow,  a  fall,  a  gynecological 
examination,  cleansing  the  abdomen  preparatory  to  a  section,  the 
straining  of  the  abdominal  muscles  in  labor,  vomiting,  defeca- 
tion, coitus,  simply  turning  in  bed,  or  often  inexplicably,  an 
ovarian  cyst  may  rupture.  A  thin-walled  cyst,  especially  a  paro- 
varian cyst,  is  most  liable  to  the  accident,  but  a  thick-walled  der- 
moid and  all  varieties  of  ovarian  cysts  may  rupture.  As  the 
ruptured  cyst  is  usually  a  thin-walled  tumor  with  simple  serous 
contents,  no  ill  effects  follow  the  rupture.  An  ovarian  tumor 
may  be  permanently  cured  in  this  way,  but  usually  the  cyst  re- 
fills. Repeated  ruptures  and  reaccumulation  of  fluid  are  re- 
ported. If  the  cyst  is  a  pseudomucin  cystadenoma  or  papillo- 
matous, rupture  may  be  followed  by  implantation  metastases.  If 
it  is  a  dermoid,  the  cystic  contents  excite  an  irritative  peritonitis 
with  symptoms  of  auto-intoxication,  and  if  the  abdomen  is  opened 
shortly  afterward,  the  cyst  contents  may  be  so  embedded  in  peri- 
toneal exudate  as  to  make  its  complete  removal  impossible,  may 
putrefy,  and  may  destroy  the  patient  by  a  septic  peritonitis.  The 
rupture  of  a  suppurating  cyst  is  naturally  followed  by  septic 
peritonitis.  Occasionally  there  may  be  intracystic  or  intra- 
abdominal bleeding  with  symptoms  of  collapse  and  shock.  Very 
rarely  these  symptoms  may  appear  and  may  prove  fatal  without 
bleeding,  though  commonly,  as  already  stated,  rupture  of  an 
ovarian  cyst  is  not  a  dangerous  accident. 

The  diagnosis  is  made  by  the  history  of  an  accident  or  strain 
followed  perhaps  by  the  disappearance  of  an  abdominal  tumor 
noticed  by  the  patient,  occasionally  with  some  symptoms  of  peri- 
toneal irritation,  as  pain,  vomiting,  tenderness  and  tympany, 
rarely  with  the  graver  symptoms  described  above.  On  examina- 
tion it  may  be  impossible  to  find  a  trace  of  tumor  if  it  had  been 
a  simple  monolocular  serous  cyst  and  was  completely  emptied 
by  the  rupture.      In  other   cases   the   tumor    may    be  felt  with 


Inflammation   and   Suppuration  489 

flaccid  or  collapsed  walls.  Free  fluid  may  be  demonstrated  in 
the  abdomen,  perhaps  in  considerable  quantities,  for  in  addition 
to  the  cyst  contents  an  ascites  may  be  excited  by  the  rupture. 

The  treatment  of  a  ruptured  cyst  is  not  necessarily  an  imme- 
diate section.  In  the  case  of  a  thin-walled  monolocular  cyst,  it 
is  better  to  give  the  patient  the  rather  remote  chance  of  a  perma- 
nent disappearance  of  the  cyst,  operating,  however,  if  it  refills. 
In  the  event  of  serious  symptoms,  or  if  one  suspects  the  ruptured 
cyst  to  be  papillomatous,  pseudomucin,  or  dermoid,  an  immediate 
operation  is  required. 

Inflammation  and  suppuration  of  ovarian  cysts  most  often  oc- 
cur in  the  puerperium,  since  the  practice  of  puncturing  them  has 
been  given  up.  The  infecting  agents  are  the  same  as  in  acute  in- 
fectious oophoritis  and  the  route  of  infection  is  likewise  the 
same — namely,  from  the  tubes,  the  bowels,  by  way  of  intestinal 
adhesions,  from  the  blood,  and  by  the  lymphatics  and  con- 
nective tissue  of  the  hilus.  Dermoids  are  more  subject  to 
suppuration  than  other  ovarian  cysts  because  they  are  so  long 
retained  in  the  pelvis,  where  they  are  liable  to  injuries  and  in- 
flammations, and  because  of  their  tendency  to  twisted  pedicle. 

The  symptoms  are  fever  and  those  of  infection  generally  or 
of  septic  intoxication.  There  may  be  an  entire  absence  of  peri- 
toneal symptoms  and  the  suppuration  is  usually  localized  strictly 
within  the  capsule  of  the  tumor. 

The  treatment  is  the  earliest  possible  removal  of  the  cyst 
entire  without  puncture.  A  delayed  operation  entails  the  danger 
of  profound  septic  intoxication  or  pyemia,  to  which  the  patient 
succumbs  in  spite  of  the  successful  removal  of  the  tumor,  or  of  a 
rupture  of  the  suppurating  cyst  into  the  peritoneal  cavity,  the 
bladder,  the  bowel,  the  vagina,  or  even  externally  through  the 
abdominal  wall.  The  partial  evacuation  which  follows  the  rup- 
ture does  not  effect  a  spontaneous  cure  :  the  patient  eventually 
dies  of  exhaustion  or  pyemia.  Rupture  into  the  peritoneal 
cavity  naturally  causes  suppurative  peritonitis  and  speedy  death. 

In  desperate  cases  it  may  be  essential  to  save  every  instant 
of  time  in  the  operation  and  all  possible  shock.  It  is  a  safe  plan 
in  such  cases  to  make  a  small  incision,  sew  the  tumor-wall  to  the 
peritoneum  with  a  few  stitches,  puncture  the  c\'st,  and  drain  its 
cavity  without  attempting  its  removal,  which  can  be  undertaken 
later  or  may  be  unnecessary,  as  adhesive  inflammation  may  oblit- 
erate its  cavity  and  the  capsule  may  shrink  to  a  fibrous  band.  ^ 

■'  By  this  plan  the  author  saved' a  patient  by  an  operation  tiiat  had  been  declined 
by  the  late  Wm.  Goodell  as  necessarily  fatal.  The  tumor  had  been  a  niultilocular 
pseudomucin  cyst,  but  all  the  locuH  were  merged  in  one  by  the  destruction  of  the  septa. 
The  infection  followed  a  vaginal  puncture  in  labor. 


490  Diseases  of  the  Ovaries 

The  Symptoms  and  Diagnosis  of  Ovarian  Tumors. — Pe- 
dunculated growths,  unless  they  are  malignant,  rarely  give 
rise  to  symptoms  until  their  size  attracts  attention.  They  ma}-, 
however,  as  small  tumors  in  Douglas's  pouch,  cause  constipation, 
t\-mpan}%  and  other  bowel  disturbances  by  pressure  on  the  rectum  ; 
or,  if  in  front  of  the  uterus,  pressing  upon  the  bladder  may  occa- 
sion vesical  irritabiHt}'  or  d}'suria.  Reflex  symptoms  are  rare, 
but  the  breasts  not  infrequently  display  functional  activity  and 
manifest  the  signs  usually  indicative  of  pregnancy.  The  effect  of 
an  ovarian  tumor  on  menstruation  is  variable.  Often  there  is 
no  change  in  the  periods,  but  quite  frequently  the  menstrual  dis- 
charge is  scanty,  irregular,  and  infrequent,  suggesting  the  idea  of 
pregnancy  and  leading  to  a  mistaken  diagnosis.  ■   Intraligamentary 


Fig.  435. — Large  ovarian  cyst  in  a  Chinese  woman.      Weight  of  tumor,  182^  pounds ; 
fluid  contents,  22  gallons    (Museum  of  the  College  of  Physicians,  Philadelphia). 

growths  cause  local  disturbance,  as  a  rule,  early  and  to  a  marked 
degree  on  account  of  the  pressure  to  which  they  and  their 
surroundings  are  subjected  in  the  attempt  to  expand  between 
the  layers  of  the  broad  ligament  and  in  the  pelvic  connective 
tissue.  A  thin-walled  parovarian  cyst  may  be  an  exception  to  the 
rule  and  often  causes  littleorno  discomfort.  Intraligamentary  cysts 
usually  produce  menorrhagia,  particularly  if  they  are  papilloma- 
tous. Malignant  growths  may  early  be  associated  with  great 
pain  and  there  is  a  rapid  development  of  ascites.  Ascites, 
however,  is  not  distinctive  of  malignancy  ;  it  occurs  in  ovarian, 
fibromata,  superficial  papillomatous  growths,  and  in  implantation 
metastases  of  pseudomucin  cysts.  It  is  possible  with  any  form  of 
ovarian  tumors.  In  the  later  stages  of  an  ovarian  cyst  the  enor- 
mous abdominal  distention,  the  emaciation  of  the  patient's  body 


Symptoms  and  Diagnosis  of  Ovarian  Tumors     491 

and  limbs,  making  her  look  like  an  appendage  of  the  tumor, 
her  incapacity,  embarrassed  respiration  and  heart  action,  and 
digestive  disturbances  are  all   so  striking  that  it  is  impossible  to 


Fig.  436. — A  ten-pound  multilocular  ovarian  cyst  displaced  under  ribs,  without  adhe- 
sions ;  right  side  ;  probably  from  tight  lacing. 


Fig.  437. — Multilocular  ovarian  cyst  adherent  in  upper  segment  of  abdomen  to 
liver,  stomach,  and  intestines.  Lower  segment  of  abdomen  perfectly  free.  Removed 
four  weeks  after  confinement. 


mistake  the  condition  ;  but  such  cases  to-day  are  rare.  An  ovarian 
cyst  is  scarcely  ever  permitted  to  exceed  the  size  ot  a  full-term 
pregnancy. 

The  examination  of  a  woman   suspected  to   have  an  ovarian 


492 


Diseases  of  the  Ovaries 


tumor  should  be  methodically  and  carefully  conducted.  In 
small  growths  still  within  the  pelvis  a  bimanual  examination 
alone  is  sufficient.  The  bowels  and  bladder  should  be  emptied. 
The  patient  is  arranged  on  a  suitable  table  with  her  trunk 
flexed  and  the  pelvis  slightly  elevated.  The  position  and  size 
of  the  uterus  are  first  determined,  and  then  the  tumor  is  caught 
between  the  finger-tips,  its  position,  size,  consistency,  and  mobil- 
ity noted.  It  may  be  possible  to  make  out  its  connection  with  the 
uterus  by  the  ovarian  ligament  and  the  tube.  While  it  is  always 
interesting  to  surmise  the  nature  of  the  ovarian  growth,  the  dif- 
ferential diagnosis  before  the  abdomen  is  opened  is  of  little  im- 
portance,   as    they  all    require    operative    treatment,   and    a   too 


Fig.  438. — Ovarian  cyst  twisted  on  its  pedicle,  removed  on  the  sixth  day  of  the  puer- 
periuni.      The  distention  of  the  upper  abdomen  is  due  to  tympany. 


persistent  or  rough  palpation  may  easily  rupture  the  tumor,  twist 
its  pedicle,  or  cause  necrosis.  Certain  facts,  however,  may  be  re- 
membered with  advantage :  Solid  tumors  are  fibromata,  sar- 
comata, carcinomata,  or  teratomata,  ascites  usually  accompany- 
ing them  ;  fibromata  are  small  in  size,  hard  in  feel,  extremely 
slow  in  growth,  have  a  comparatively  smooth  outline,  are  pedun- 
culated and  freely  mobile.  Carcinomata  and  sarcomata  are  irregu- 
lar in  outline,  usually  bilateral,  soft  in  consistency,  and  adherent. 
Of  the  cystic  growths  the  fluid  contents  are  most  evident  in 
simple  serous  cysts  and  parovarian  cysts,  the  latter  having  thin- 
ner walls.  Dermoids  have  an  indistinctly  cystic  feel,  an  almost 
doughy  consistency,  and  a  regular  spherical  outline.      They  may 


Symptoms  and  Diagnosis  of  Ovarian  Tumors    493 

empty  into  the  bladder  or  bowel  and  discharge  characteristic  con- 
tents with  the  urine  or  feces.  A  radiograph  may  show  their 
bony  contents.  If  they  lie  in  front  of  the  uterus  and  are  dis- 
placed to  the  side  from  which  they  grow,  they  immediately  re- 
turn to  their  former  position  (Kiister's  sign ;  not  positive).  Pseudo- 
mucin  cysts  are  often  irregular  in  outline  and  consistency ;  a 
distinctly  cystic  area  may  be  bordered  by  solid  lumpy   masses. 


Fig.  439. — Obesity.  Referred  to  author  as  an  ovarian  cyst.  The  finger-tips  on 
the  flanks  could  be  approximated  under  the  tumor.  Resonant  note  on  percussion 
everywhere. 

Serous  glandular  cysts,  if  they  are  intraligamentary  and  papillo- 
matous, especially  if  the  papillomata  are  superficial,  may  present 
the  physical  signs  of  a  solid  malignant  tumor. 

It  is  sufficient  for  all  practical  purposes  to  recognize  an 
ovarian  tumor  which  must  be  removed.  The  exact  differential 
diagnosis  can  be  made  when  the  abdomen  is  opened.  In  the  ex- 
amination of  large  ovarian  tumors,  inspection,  palpation,  and  per- 


494 


Diseases  of  the  Ovaries 


cussion  of  the  abdomen  must  be  practised  in  addition  to  the  com- 
bined or  bimanual  examination.  The  appearance  of  a  very  large 
cyst  is  distinctive  :  The  huge  spherical  abdomen,  with  distended 


Fig.  440. — Ascites  with  sarcoma  of  the  uterus.  Sent  to  Howard  Hospital  as  an 
ovarian  cyst.  No  corona  of  resonance  ;  shifting  dullness  with  changes  of  posture. 
Uterine  tumor  appreciable  on  bimanual  examination. 


Fig.  441. — Ascites  from  cirrhosis  of  the  liver.      Pyramidal  abdomen  ;  other  signs  of 
ascites  as  above.      Referred  to  author  for  operation  as  an  ovarian  cyst. 


veins  in  the  skin,  the  emaciated  body,  face,  and  limbs  present  a 
spectacle  easily  recognizable.  Moderate-sized  growths  cause  no 
typical  change  in  the  abdomen.  The  distention  might  just  as  well 
be  due  to    pregnancy  or   any  other    abdominal    tumor.      Occa- 


Treatment  of  Ovarian  Tumors  495 

sionalh'  the  C}-st  is  displaced  into  the  upper  abdomen  and  is 
apparently  unconnected  with  the  pelvic  organs.  ^  Not  infrequently 
an  irregularity  in  outline  of  the  tumor  is  evident  through  the  ab- 
dominal wall,  indicative  of  a  pseudomucin  cyst  or  of  malignancy. 
Percussion  yields  a  dull  note  over  the  tumor  and  a  resonant  note 
around  its  periphery  in  the  flanks  and  epigastrium  (the  corona  of 
resonance).  Occasionally  coils  of  intestines  may  slip  in  front  of  the 
tumor,  but  deep  percussion  and  palpation  should  eliminate  this 
possible  source  of  error.  A  t}'mpanitic  note  over  the  tumor  itself 
may  be  due  to  intrac}'stic  gas-formation  if  the  tumor  is  infected,  or 
to  intestinal  gas  if  a  fecal  fistula  communicates  with  the  tumor. 
The  palpation  of  the  tumor  determines  its  consistency,  size,  and 
mobility.  In  c}'stic  tumors  the  fluctuation  wave  may  often  be 
elicited  by  tapping  one  side  sharply  with  the  finger-tips  of  one 
hand  while  those  of  the  other  are  held  steadily  against  the  opposite 
side  of  the  tumor.  In  pseudomucin  cysts  a  lumpy,  solid  feel 
alternating  with  a  cystic  sensation  can  usually  be  made  out. 

In  the  bimanual  examination  the  uterus  is  found  retroverted, 
pushed  forward  against  the  symphysis,  crowded  to  one  side,  or 
in  a  position  of  anteversion  depressed  against  anterior  vaginal 
vault.  The  characteristic  feel  of  a  cystic  growth  is  best  appreci- 
ated with  the  finger-tips  in  the  vaginal  vault  wherever  the  tumor 
is  most  prominent  while  counterpressure  is  made  with  the  free 
hand  over  the  top  of  the  tumor. 

Tapping  an  ovarian  tumor  for  diagnostic  purposes  is  no 
longer  justifiable.  It  yields  no  information  of  value  and  subjects 
the  patient  to  the  dangers  of  intracystic  hemorrhage,  infection, 
implantation  metastasis,  and  insures  an  adhesion  between  cyst- 
wall  and  peritoneum  which  complicates  a  subsequent  operation. 

Treatment  of  Ovarian  Tumors. — If  papillary  cysts  of  the 
broad  ligament  are  included  among  the  malignant  growths  of 
the  ovary,  which  is  clinically  justifiable,  about  a  quarter  of  all 
ovarian  tumors  are  malignant.^  The  glandular  cysts  destroy 
life  by  an  unrestrained,  continuous  growth.  Even  the  least 
dangerous  cysts,  the  simple  serous  and  the  parovarian,  can  never 
be  expected  to  undergo  a  spontaneous  cure  and  are  liable,  to  all 
the  accidents  of  ovarian  tumors.  Every  true  ovarian  neoplasm, 
therefore,  should  be  removed  as  soon  as  practicable  after  the 
diagnosis  has  been  made.      That  the  tumor  is  small  and  has  given 

1  I  have  seen  this  displacement  three  times  ;  twice  due  to  tight  lacing,  once  to 
tlie  fact  that  the  tumor  was  elevated  in  pregnancy,  adhered  to  the  liver,  and  could 
not  descend  with  the  involuting  womb. 

~  Pfannenstiel  gives  the  following  statistics  :  Schultz  found  27  per  cent,  of 
ovarian  tumors  malignant;  Leopold,  22  to  26  per  cent.;  Freund,  21.6  per  cent.; 
Cohn,  16  percent.;  Olshausen,  15  percent.;  Hecht,  17. 8  per  cent.;  Fontane,  18.9 
per  cent.;  Rinck,  15  per  cent.;  Pfannenstiel,  20  per  cent. 


496  Diseases  of  the  Ovaries 

rise  to  no  disturbance  are  no  arguments  in  favor  of  delay.  If 
the  growth  should  prove  malignant,  it  can  not  be  removed  too 
soon.  Even  if  it  is  not,  it  is  an  advantage  from  every  point  of 
view  to  remove  it  before  complications  occur  or  a  large  size  is 
attained.  In  the  event  of  a  twisted  pedicle,  suppuration,  pressure 
symptoms,  rupture,  or  intracystic  bleeding  there  is  indication  for 
immediate  operation.  Rapid  growth  also  forbids  delay ;  it  points 
toward  malignancy,  or  if  the  tumor  proves  to  be  benign  in  the 
pathological  sense,  it  promises  a  speedy  destruction  of  the  patient 
by  pressure  symptoms  and  exhaustion.  There  may  be  a  condi- 
tion of  the  patient's  general  health  warranting  a  temporary  post- 
ponement of  the  operation,  but  there  are  very  few  contraindica- 
tions indeed  which  justify  indefinite  delay.  Ovarian  tumors  have 
been  removed  repeatedly  with  success  in  early  infancy  and  in  ex- 
treme old  age,  ^  in  pregnancy,  in  the  midst  of  an  attack  of  peri- 
tonitis, and  with  imperfect  kidney  action.  The  author  has  suc- 
cessfully removed  a  large  pseudomucin  glandular  cyst  from  a 
woman  with  an  aneurysm  of  the  arch  of  the  aorta,  in  process  of 
cure,  but  projecting  from  her  chest  through  an  eroded  sternum. 
Obviously,  however,  there  may  be  positive  contraindications  to 
ovariotomy  in  conditions  of  the  general  health  threatening  to 
terminate  the  patient's  life  in  a  short  time  and  in  malignant  tumors 
with  metastases,  dense  adhesions,  and  involvement  of  neighboring 
organs,  making  the  operation  evidently  a  hopeless  one.  But 
even  in  such  a  case  an  exploratory  incision  is  often  indicated  to 
evacuate  the  ascites  and  to  determine  positively  that  the  condition 
is  beyond  radical  surgical  aid. 

Puncture  of  an  ovarian  ri'i'/ through  the  abdominal  wall  is  only 
justifiable  if  there  is  a  positive  contraindication  to  operation  or  in 
the  extremely  rare  cases  to-day  in  which  the  tumor  has  reached  a 
colossal  size.  In  the  latter  case  it  may  be  considered  safer  to  punc- 
ture the  cyst  some  hours  or  days  before  the  operation  to  relieve  the 
embarrassment  of  heart  and  lungs  and  to  avoid  the  danger  of  too 
sudden  a  reduction  of  intra-abdominal  pressure.  ^  The  puncture 
is  made  with  a  simple  trocar  and  canula  or  with  an  aspirating 
needle  attached  to  a  large  bottle  from  which  the  air  is  exhausted. 
The  point  on  the  abdomen  to  be  punctured,  which  should  be  in 
the  linea  alba  about  half  way  between  the  symphysis  and  umbili- 

^  Owens  (London  "Lancet,"  Marcli  2,  1895)  operated  on  a  woman  eighty-seven 
years  old.  Kelly's  and  Sherwood's  ("Johns  Hopkins  Hospital  Report,"  vol.  iii) 
statistics  of  over  100  operations  on  women  past  seventy  years  of  age  give  a  mortality 
of  12  per  cent.  The  operations  in  infancy  and  early  childhood  give  a  higher  mortality 
because  such  a  large  proportion  of  the  tumors  at  this  time  of  life  are  malignant. 

2  The  author  resorted  to  this  measure  in  the  largest  tumor  he  has  ever  removed. 
Forty-eight  hours  before  the  o]jerati(jii  6  gallons  of  fluid  were  drawn  oft.  The  tumor 
rapidly  refilled  and  weighed  90  pounds  when  removed. 


Treatment  of  Ovarian  Tumors  497 

cus,  is  as  carefully  cleansed  as  for  a  major  operation.  The  trocar 
and  canula,  or  aspirating  needle  with  a  caliber  not  less  than 
5  mm.  (1-  inch),  are  boiled.  The  patient  lies  upon  her  back  or 
in  a  senii-recumbent  position  ;  the  operator,  with  cleansed  and 
gloved  hands,  punctures  the  abdomen  and  cyst-wall  deeply 
enough  to  insure  the  entrance  of  the  canula  well  within  the  chief 
cyst  cavity ;  an  assistant  exerts  pressure  over  the  top  of  the 
tumor  or  the  upper  abdomen  so  as  to  keep  the  cyst-wall 
approximated  to  the  abdominal  wall;  after  the  evacuation  of  the 
cyst  and  the  withdrawal  of  the  canula  the  puncture  wound  is  im- 
mediately covered  with  a  small  piece  of  sterile  gauze  which  is 
held  in  place  b}'  a  liberal  application  of  collodion.  If  the  canula 
drains  off  only  a  small  amount  of  fluid,  either  the  chief  cyst 
cavity  has  not  been  penetrated  or  the  cyst  is  divided  into  so 
many  loculi  that  the  evacuation  of  one  or  two  has  no  effect  upon 
its  bulk.  In  the  former  case,  by  reinserting  the  needle  and 
cautiously  pushing  it  in  different  directions  the  main  cyst  cavity 
may  be  found ;  in  the  latter,  nothing  can  be  gained  whatever  by 
tapping,  and  the  attempt  should  be  given  up.  Puncture  of  an 
ovarian  cyst  by  the  vagina  is  not  to  be  recommended.  Puncture 
by  the  rectum  as  was  once  practised  is  absolutely  unjustifiable. 
The  cyst  rapidly  refills  after  puncture.  English  literature  con- 
tains the  records  of  ovarian  c}'sts  tapped  every  two  or  three 
weeks  for  some  years,  with  the  removal  in  the  aggregate  of 
hundreds  of  gallons  of  fluid. 

The  preparation  for  the  removal  of  an  ovarian  cyst  is  the 
same  as  for  any  abdominal  section  (page  600).  The  same  in- 
struments are  required,  but  in  addition  a  trocar  to  puncture  the 
c\'st,  several  broad-bladed  catch-forceps  with  roughened  inter- 
nal surfaces  to  catch  the  cyst-walls,  and  one  or  two  heavy 
volsella  forceps  to  seize  the  tumor  if  it  is  soHd  should  be  added 
to  the  instrument  tray. 

The  incision  is  made  in  the  usual  manner  in  the  median  line, 
but  not  extending  at  first  too  near  the  symphysis  for  fear  the 
bladder  may  be  higher  than  usual.  After  the  peritoneum  is 
opened  the  incision  may  be  lengthened  toward  the  symphysis 
after  the  position  of  the  bladder  is  determined.  As  soon  as  the 
abdomen  is  opened  the  color  and  appearance  of  the  tumor  should 
be  observed  and  the  finger-tip  should  tap  the  wall  lightly  to  de- 
termine whether  the  contents  are  fluid  or  semi-solid.  A  multiloc- 
ular  pseudomucin  cyst  with  a  large  predominant  cyst-space  has 
a  cerulean  or  sky-blue  color.  A  perfectly  white  cyst-wall  indi- 
cates a  dermoid,  a  pseudomucin  cyst  with  jelly-like  contents,  or 
a  papillar}^  cyst.  A  monolocular  simple  serous  cyst  and  a  par- 
ovarian cyst  have  thin  walls  through  which  the  clear  serous 
32 


498  Diseases  of  the  Ovaries 

contents  show  plainly.  Next  the  operator's  gloved  hand  is  swept 
around  the  abdominal  cavity  between  the  tumor  and  the  peri- 
toneum to  see  if  there  are  adhesions.  If  there  are  none,  if 
the  cyst  is  comparatively  thin-walled,  sky-blue  in  color,  plainly 
fluctuating  on  palpation  and  large  in  size,  it  is  punctured  with 
the  trocar,  to  which  a  rubber  tube  is  attached  and  the  con- 
tents evacuated  into  a  bucket  at  the  operator's  feet ;  or,  what  is 
often  quicker  and  more  convenient,  the  cyst-wall  is  cut  with  a  knife 
and  the  contents  allowed  to  flow  out  toward  the  woman's  thighs. 
Before  puncturing  or  incising  the  cyst  the  abdominal  wound 
should  be  protected  with  gauze  pads  to  avoid  implantation 
metastases.  While  the  cyst  is  being  evacuated  pressure  is  exerted 
by  an  assistant  over  the  abdomen,  and  as  the  cyst-walls  become 
flaccid  they  are  seized  with  the  forceps  provided  for  the  purpose, 
the  collapsed  tumor  is  gradually  pulled  out  through  the  wound 
and  laid  upon  the  sterile  sheet  covering  the  woman's  sym- 
physis. The  pedicle  comes  plainly  into  view.  If  it  is  not  too 
broad  it  is  transfixed  in  the  middle  with  a  pedicle  needle  armed 
with  medium-sized  silk.  ^  The  loop  of  the  ligature  is  caught  by 
an  assistant  and  the  needle  withdrawn  ;  the  loop  is  cut ;  one  liga- 
ture is  tied  firmly  around  the  half  of  the  pedicle  toward  the 
operator  and  the  ends  cut  off  short ;  the  other  ligature  is  tied 
around  the  remaining  half  of  the  pedicle  and  the  ends  are 
doubled  back  again  around  the  whole  pedicle  below  the  puncture 
point  of  the  pedicle  needle.  This  method  of  ligating  gives  abso- 
lute security  against  hemorrhage,  and  if  the  aseptic  technic  is 
what  it  should  be,  there  is  nothing  to  be  feared  from  the  stump 
or  ligature  in  the  future.  After  tying  the  last  ligature,  two  hemo- 
stats  are  fastened  to  each  side  of  the  pedicle  about  a  quarter  of  an 
inch  above  the  ligature,  the  pedicle  is  cut  across  above  the  hemo- 
stats,  and  the  tumor  is  dropped  into  a  vessel  held  ready  to  re- 
ceive it  by  a  nurse.  The  stump  is  then  carefully  inspected  for 
bleeding  ;  if  it  is  dry,  the  hemostats  are  removed  and  the  pedicle 
is  dropped.  Some  operators  prefer  to  sew  the  peritoneum  over 
raw  surface  of  the  stump,  others  cut  the  pedicle  with  a  cautery 
knife,  and  it  has  been  proposed  to  sew  the  stump  to  the  anterior 
abdominal  wall  to  correct  a  tendency  to  retroversion  of  the 
uterus  and  to  avoid  adhesions  between  the  stump  and  intestines. 
After  the  removal  of  the  tumor,  the  toilet  of  the  peritoneum  is 
carefully  made.  Whether  a  trocar  or  a  knife  has  been  used  to 
puncture  the  cyst,  some  cyst-contents  often  escape  into  the  peri- 

'  The  author,  after  a  prolonged  trial  of  silk  and  catgut,  prefers  silk  in  all  clean, 
aseptic  cases.  It  can  be  tied  more  firmly  and  the  knot  will  not  slip  nor  the  ligature 
loosen.  Every  one  who  uses  catgut  exclusively  will  occasionally  have  to  deplore  a 
death  from  secondary  hemorrhage. 


Treatment  of  Ovarian  Tumors  499 

toncal  cavity.  They  should  be  carefully  removetl.  The  other 
ovary  is  hfted  out  of  the  abdominal  cavity  and  closely  inspected. 
If  it  is  not  diseased  it  is  not  removed  unless  the  ovarian  tumor  is 
malignant  or  papillary.  The  pads  used  to  protect  tiie  abdominal 
wound  and  to  cleanse  the  abdominal  cavity  are  removed  and 
counted.  A  count  is  made  of  all  the  pads  prepared  for  the 
operation  ;  ^  all  of  them  being  accounted  for,  the  abdomen  is 
closed  in  the  usual  manner  (page  630).  If  the  tumor  is  of 
moderate  size,  if  it  is  divided  into  loculi  so  numerous  that  the 
evacuation  of  a  Sew  has  no  perceptible  influence  on  its  bulk, 
if  there  is  inflammation  or  suppuration,  if  there  is  any  suspicion 
that  the  cyst  is  a  dermoid  or  papillary,  it  should  not  be  punc- 
tured during  the  operation,  but  should  be  removed  whole  no 
matter  how  large  an  incision  is  required.  It  is  better  to  have  a 
long  abdominal  wound  than  to  lose  the  patient  later  from  im- 
plantation metastases  or  to  contaminate  the  peritoneal  cavity  with 
putrescible  or  infected  contents  that  may  be  difficult  or  impossible 
to  remove. 

Adhesions  between  the  cyst-wall,  the  peritoneum  of  the  ante- 
rior abdominal  wall,  the  pelvic  peritoneum,  the  omentum,  the 
intestines,  the  mesentery,  the  liver,  spleen,  and  kidneys  may  re- 
quire special  attention. 

The  adhesions  between  the  cyst-wall  and  the  anterior  abdom- 
inal wall  are  commonly  broken  up  with  ease  by  sweeping  the 
hand  around  between  the  tumor  and  the  abdominal  wall.  As 
successive  portions  of  the  tumor  after  its  evacuation  are  pulled 
out  of  the  wound,  adhesions  not  at  first  accessible  are  easily 
reached  and  are  severed  in  the  same  way.  Care  must  be  exercised 
not  to  mistake  the  peritoneum  for  the  cyst-wall  and  not  to  strip 
it  off  from  the  fascia.  If  the  peritoneum,  owing  to  dense  and 
widespread  agglutination  with  the  cyst-wall,  can  not  be  lifted  away 
from  the  latter  and  incised  separately,  the  abdominal  incision  is 
lengthened  until  a  place  is  reached  where  the  adhesions  cease  or 
the  cyst-wall  is  incised,  the  tumor  evacuated,  and  a  careful  study 
is  made  of  the  different  layers  to  detect  the  true  area  of  cleavage 
between  the  peritoneum  and  the  cyst-wall.  The  adhesions  may 
take  the  form  of  thick  bands  or  isolated  areas  of  agglutination, 
too  strong  to  be  easily  and  safely  torn  across.  This  is  often  the 
case  if  the  tumor  has  been  tapped.  ^  Such  adhesions  must  often 
be  cut.  The  quickest  and  safest  way  is  to  clamp  each  one  with 
a  hemostat  and  to  cut  the  adhesion  between  the  instrument  and 

1  The  author  uses  an  invariable  number,  fifteen,  for  every  abdominal  section. 

2  The  author  once  removed  a  cyst  that  had  been  tapped  twenty  times,  each  punc- 
ture resulting  in  a  strong  adhesion  that  had  to  be  cut.  Such  cases  are  not  often  seen 
to-day. 


500  Diseases  of  the  Ovaries 

the  tumor-wall.  The  hemostats  are  counted  as  they  are  clamped  ; 
the  original  number  provided  for  the  operation  should  also  always 
be  known  ;  the  hemostats  are  recounted  as  they  are  removed,  and 
a  count  is  made  of  the  total  number  in  the  instrument  tray  before 
the  abdomen  is  closed.  After  the  removal  of  the  tumor  a  liga- 
ture of  fine  silk  or  catgut  is  tied  under  each  hemostat  before  it  is 
removed.  If  the  areas  of  adhesion  are  too  broad  to  be  treated 
in  this  manner  and  an  oozing  surface  remains  after  severing  the 
adhesions,  the  bleeding  may  be  checked  by  pressure  with  gauze 
pads,  the  application  of  very  hot  water,  mattress  or  purse-string 
sutures  surrounding  the  bleeding  areas,  approximating  the  bleed- 
ing surface  to  the  opposite  abdominal  wall,  or  transfixing  the  ab- 
dominal wall.  Ligation  of  the  epigastric  artery  has  been  effectual. 
The  application  of  turpentine,  Monsel's  solution,  and  the  actual 
cautery  have  also  been  successful,  but  these  agents  are  inferior  to 
the  methods  previously  described. 

Adhesions  between  the  tumor  and  the  pelvic  peritoneum  may 
be  very  firm.  They  are  broken  up  as  in  operations  for  pyosal- 
pinx,  by  finding  the  area  of  cleavage,  inserting  the  finger-tips, 
and  by  a  to-and-fro  movement  .separating  the  united  structures. 
Rupture  by  traction  or  the  use  of  cutting  instruments  may  be 
required.  Hemorrhage  must  be  controlled  cautiously,  as  the 
careless  use  of  needles  and  ligatures  may  occlude  the  ureter  or 
wound  a  large  vessel. 

Omental  adhesions  are  easily  dealt  with.  They  may  be 
broken,  or  if  they  contain  large  blood-vessels,  as  is  not  infre- 
quently the  case,  should  be  ligated  and  cut. 

Intestinal  adhesions  are  usually  thin  sheets  of  false  mem- 
brane readily  broken,  but  the  connection  may  be  so  intimate  be- 
tween tumor  and  bowel  that  the  outer  layers  of  the  tumor-wall 
must  be  left  upon  the  intestinal  coat  to  avoid  injury  to  the  latter. 
Raw  spaces  on  the  intestines  should  be  covered  with  peritoneum 
by  mattress  or  Lembert  sutures. 

In  separating  adhesions  to  the  mesentery  care  must  be  exer- 
cised not  to  ligate  important  blood-vessels,  which  might  result  in 
gangrene  of  the  intestinal  loop  which  they  nourished. 

Adhesions  to  the  abdominal  viscera  must  be  separated  with 
great  care,  especially  in  the  case  of  the  under  surface  of  the  liver, 
so  that  lacerations  and  consequent  hemorrhages  may  be  avoided. 
Nothing  is  more  embarrassing  than  the  bleeding  from  a  torn 
liver.  The  actual  cautery  may  stop  it  or  it  may  be  controlled 
by  gauze  packing. ^ 

^  In  a  case  of  the  author's  no  other  means  would  control  the  bleeding.  The 
space  between  the  stomach  and  liver  was  firmly  packed  with  a  long  strip  of  gauze, 
the  end  of  which  protruded  from  the  upper  angle  of  the  abdominal  wound.  It  was 
removed  in  twenty-four  hours.      The  patient  made  a  perfect  recovery. 


Treatment  of  Ovarian  Tumors  501 

In  cases  of  tivistcd  pedicle  the  tumor  is  turned  on  its  longi- 
tudinal axis  until  the  torsion  disappears,  before  the  pedicle  is 
ligated  or  the  tumor  is  removed.  If  there  is  extensive  throm- 
bosis of  the  veins  of  the  stump  a  mass  ligature  should  be 
avoided.  The  vessels  are  tied  separately.  The  tumor,  which  is 
often  almost  black  in  color  and  contains  effused  blood  in  a  highly 
putrescible  condition,  if  not  actually  infected,  should  be  removed 
unopened. 

Intraligamentary  tumors  must  usually  be  dealt  with  by  enu- 
cledtion.  A  double  ligature  is  applied  to  the  ovarian  artery,  to 
the  lateral  side  of  the  tumor,  including  the  suspensory  ligament 
of  the  ovary  in  the  small  strip  of  broad  ligament  running  free  be- 
tween the  tumor  and  the  pelvic  wall.  An  incision  is  then  made 
in  the  free  border  of  the  broad  ligament  between  the  ligatures. 
The  tumor-wall  is  thus  exposed,  and  enucleation  by  inserting 
the  finger-tips  between  the  broad  ligament  and  the  tumor-wall 
is  usually  easy,  the  incision  in  the  broad  ligament  being  enlarged 
on  its  anterior  face  and  the  tumor  being  rolled  out  toward  the 
pelvic  wall  or  toward  the  median  line,  as  is  most  easy  and 
practicable  in  the  individual  case.  The  blood-vessels  thus  rup- 
tured are  small  and  the  bleeding  usually  insignificant.  If  there 
is  active  oozing  at  the  base  of  the  cavity  left  after  the  enucleation 
of  the  tumor,  ligatures,  if  used  at  all,  must  be  applied  with  the 
greatest  caution  on  account  of  a  possible  occlusion  of  the  ureter. 
It  is  usualh'  easier  to  enucleate  an  intraligamentary  tumor  if  it 
is  unruptured.  Thin-walled  cysts  may  easily  be  perforated  or 
ruptured  by  the  manipulation  of  the  operator.  In  such  a  case 
the  tumor-wall  is  seized  by  catch-forceps  and  the  cyst-wall  is 
then  stripped  off  from  its  connection  with  the  inner  surface  of  the 
broad  ligament,  successive  portions  of  it  being  held  taut  by  an 
assistant  while  the  operator  frees  it  from  its  attachments. 

In  bilateral  intraUgamentary  tumors  the  procedure  is  the 
same  on  each  side.  A  uterine  tumor  is  not  infrequently  asso- 
ciated with  double  intraligamentary  growths,  in  which  case  a 
hysterectomy  is  added  to  the  bilateral  enucleation.  Hysterec- 
tomy is  indicated  if  the  broad  ligament  growths  are  malig- 
nant, and  it  may  possibly  be  required  also  to  more  certainly 
control  hemorrhage,  even  if  the  uterus  itself  is  healthy.  A 
puzzling  problem  after  the  removal  of  an  intraligamentary  tumor 
is  what  to  do  with  the  raw  cavity,  often  of  great  size,  from  which 
it  was  enucleated.  If  there  is  no  oozing  to  speak  of  it  may  be 
sufficient  to  sew  the  flaps  of  broad  ligament  over  it  and  thus  shut 
it  off  from  the  peritoneal  cavity,  or  simply  to  leave  the  raw  sur- 
face exposed,  cutting  away  redundant  portions  of  the  broad  liga- 
ment ;  but  the  author  has  found  it  safer  and  more  satisfactory,  in 


502  Diseases  of  the  Ovaries 

the  majority  of  cases,  if  the  tumor  is  large,  to  perforate  the 
vaginal  vault  with  a  sharp-pointed  scissors  as  close  to  the  cervix 
as  possible  and  a  little  posterior  to  it,  to  pack  the  cavity  with  a 
strip  of  sterile  gauze,  pushing  the  end  out  into  the  vagina,  and  to 
sew  the  flaps  of  broad  ligament  over  the  gauze  with  catgut,  thus 
excluding  it  from  the  peritoneal  cavity.  It  is  often  advisable  to 
cut  away  redundant  portions  of  the  broad  ligament  before  sewing 
the  flaps.  The  gauze  is  removed  by  the  vagina  at  the  end  of 
forty-eight  hours  and  is  replaced  by  a  T-shaped  rubber  drainage 
tube  through  which  the  cavity  is  irrigated  daily  after  the  third 
day  with  sterile  water  until  all  discharge  ceases  and  the  former 
bed  of  the  tumor  is  obliterated.  It  requires,  as  a  rule,  ten  days 
to  secure  this  result. 

If  the  tumor  is  adherent  to  the  broad  ligament  or  to  the  pel- 
vic fascia  on  its  base,  as  may  be  the  case  in  papillary  and  malig- 
nant growths,  it  may  be  impossible  to  enucleate  it  entire.  Por- 
tions are  left  behind  in  the  depth  of  the  tumor  bed.  It  is  often 
impracticable  to  remove  these  fragments  completely.  In  such  a 
case  an  effort  should  be  made  to  destroy  them  by  the  actual 
cautery.  The  growth  of  a  subserous  tumor  between  the  layers  of 
the  mesocolon  may  be  a  most  embarrassing  complication.  Care 
must  be  exercised  not  to  ligate  the  mesenteric  vessels  too  exten- 
sively for  fear  of  gangrene  of  the  bowel.  An  excision  of  a  por- 
tion of  the  intestine  and  an  end-to-end  anastomosis  may  be 
required. 

Stippuratiug  and  infected  ovarian  tnniors  must  be  removed,  if 
possible,  without  rupturing  them.  Should  they  rupture  and  dis- 
charge any  part  of  their  contents  into  the  abdominal  cavity,  the 
toilet  of  the  peritoneum  must  be  carefully  made  by  removing 
every  particle  of  discharge  with  dry  gauze  pads.  All  the  ligature 
material  must  be  of  catgut  and  the  abdomen  should  be  drained. 
It  is  occasionally  wiser,  on  account  of  the  patient's  condition,  not 
to  attempt  the  removal  of  a  suppurating  cyst,  but  to  rest  content 
with  sewing  it  to  the  abdominal  wall,  evacuating  its  contents,  and 
draining  the  sac.  Later,  if  necessary,  the  cyst-wall  may  be  re- 
moved, but  nothing  more  may  be  required,  the  cyst-cavity  being 
obliterated  and  the  cyst-wall  shriveling  into  a  small  mass  that 
causes  no  symptoms. 

Riiptnrc  of  the  cyst  into  the  abdominal  cavity  usually  indicates 
an  abdominal  section  and  the  careful  removal  of  the  cyst-contents 
from  Douglas's  pouch,  the  region  of  the  kidneys,  and  wherever 
else  they  may  be  found.  It  is  particularly  important  to  remove 
with  pads  and  the  hands  all  of  the  gelatinous  material  from  a 
pseudomucin  cyst,  else  implantation  metastasis  may  develop.  It 
may  be  difficult  or  impossible  to  remove  the  material  from  a  der- 


Treatment  of  Ovarian  Tumors  503 

moid  cyst  if  the  rupture  has  occurred  many  hours  before  the 
operation.  It  becomes  embedded  in  plastic  exudate  and  can  not 
be  wiped  or  waslied  away.  Fresh  c\st-contents  from  a  dermoid 
are  not  infectious,  dirty  as  they  may  appear,  but  they  are  putresci- 
ble,  and  after  exposure  to  the  atmosphere,  if  not  removed  from 
the  abdomen,  may  cause  septic  peritonitis.  Drainage  is  of  no 
a\ail  if  the  c}'st-contents  are  widely  distributed  o\'er  the  whole 
abdominal  cavity.  The  abdomen  must  be  closed,  taking  the 
chance  of  the  decomposition  of  the  material  left  within  it.  If  the 
cyst  has  ruptured  into  the  bowel  or  bladder,  the  tumor  must  be 
treated  as  an  infected  one  :  After  its  removal  the  opening  into 
the  bowel  or  bladder  should  be  closed  by  sutures  if  the  edges 
are  healthy  enough  or  can  be  made  sufficiently  so  by  trimming 
to  give  reasonable  assurance  that  they  will  hold.  Otherwise  the 
opening  is  allowed  to  gape,  drainage  of  the  pelvis  and  abdomen 
being  naturally  required  (page  633).  In  any  event,  whether 
sutures  are  used  or  not,  drainage  is  usually  necessary. 

In  malignant  tumors,  papillary  cysts,  and  implantation  metas- 
tases of  proliferating  adenomata  one  may  be  confronted  with  the 
problem  of  dealing  with  extensions  of  the  growth  beyond  the 
o\^ary.  The  common-sense  rule  should  be  followed  to  remove 
all  of  the  growth  possible  unless  the  operation  promised  to  be 
too  formidable  for  the  results  that  might  be  secured.  Thus,  in 
papillary  growths  a  complete  cure  may  be  effected  by  removing 
papillomata  from  the  surface  of  the  uterus,  the  broad  ligaments, 
and  neighboring  structures,  in  addition  to  the  removal  of  the 
ovaries.  In  pseudomyxoma  peritonei,  also,  it  may  be  possible  to 
secure  a  permanent  good  result  by  the  removal  of  all  or  of  a 
great  portion  of  the  growth,  and  at  any  rate  an  amelioration 
of  the  condition  for  a  long  time.  With  true  malignant  tumors 
the  case  is  different.  If  the  sarcoma  or  carcinoma  has  spread 
much  beyond  the  ovary  it  is  doubtful  if  any  good  is  even 
temporarily  secured  by  the  removal  of  a  part  of  the  growth. 
Recurrence  is  certain,  and  an  immediate  death  is  only  too  likely 
to  cast  unnecessary  discredit  upon  the  operator,  as  the  subjects 
of  malignant  abdominal  growths  do  not  stand  operations  well. 
The  evacuation  of  the  ascites  and  the  removal,  perhaps,  of  well- 
pedunculated  masses  are  all,  as  a  rule,  that  should  be  attempted. 

Tlie  treatment  of  the  other  ovary  and  of  the  litems  in  cases  of 
ovarian  tumors  is  an  important  question  on  which  the  operator 
should  have  a  definite  and  well-advised  opinion.  In  a  woman 
of  child-bearing  age,  the  other  ovary,  if  healthy,  should  not  be 
disturbed,  except  in  cases  of  sarcoma,  carcinoma,  endothelioma, 
and  papilloma  of  the  ovary.  Even  if  one  ovary  in  these  cases 
appears  healthy,  clinical  experience  teaches  that  it  will  probably 


504  Diseases  of  the  Ovaries 

develop  a  malignant  growth  in  the  near  future,  and  it  should  be 
removed.  In  true  malignant  disease  of  one  or  both  ovaries  the 
uterus  should  also  be  removed.  Recurrence,  metastasis,  or  ex- 
tension of  the  growth  in  a  uterus  left  behind  has  been  observed. 

If  an  ovarian  tumor  of  any  kind  is  removed  from  a  woman 
near  the  menopause  or  past  the  age  when  child-bearing  is  likely, 
it  is  more  prudent  to  remove  both  ovaries.  Proliferating  cysts 
and  dermoids  are  not  uncommonly  bilateral  or  affect  first  one 
ovary  and  then  the  other.  The  chance  of  a  second  operation 
in  young  women  contemplating  matrimony  or  desirous  of  bearing 
children  must  be  taken.  In  older  patients  it  is  unnecessary  to 
run  the  risk.  In  the  former  class  of  women  with  benign  new- 
growths  in  both  ovaries,  fertility  has  been  preserved  by  the  com- 
plete removal  of  an  ovarian  tumor  on  one  side  and  the  exsection 
of  a  smaller  growth  from  the  other  ovary,  leaving  healthy  ovarian 
structure.^ 

Foreign  bodies  in  the  ovary  have  been  reported  by  Haveland 
and  Liebmann,^  who  found  respectively  a  sewing  needle  and 
a  darning  needle  in  the  ovary. 

Echi7iococc7is  cysts  of  the  ovary  have  been  reported  in  connec- 
tion with  these  parasitic  growths  in  the  abdomen  and  pelvis.  A 
primary  infection  of  the  ovary  has  been  observed  by  Pean,  but  is 
exceedingly  rare. 

Implantation  and  Transplantation  of  the  Ovaries. — It  has  been 
demonstrated  by  experiments  upon  animals  and  by  clinical  ob- 
servations in  women  that  ovaries  may  be  implanted  from  another 
individual  or  may  be  transplanted  to  an  abnormal  situation,  with 
continued  nutrition,  physiological  activity,  and  consequent  im- 
pregnation. The  utilization  of  this  possibility  in  gynecology 
opens  up  an  interesting  field.  The  disagreeable  consequences  of 
castration  might  possibly  be  avoided  by  ovarian  implantation, 
sewing  a  freshly  removed  ovary,  kept  in  warm  normal  salt  solu- 
tion and  sewed  by  catgut  or  fine  silk  to  the  peritoneum  of  the 
broad  ligament,  in  Douglas's  pouch  or  in  the  vesico-uterine  re- 
dupHcation  of  the  peritoneum.  A  short  incision  is  made  in  the 
peritoneum  and  the  hilus  of  the  ovary  is  implanted  in  raw  surface, 
the  edges  of  the  peritoneum  being  brought  about  half-way  up 
the  free  ovarian  surface.  Sterility  following  castration,  atrophy, 
or  congenital  defects  of  tlie  ovary  might  possibly  be  cured  in 
this  way. 

Impregnation  has  f(jllowed  the  transplantation  of  the  ovary 
into  the  lumen  of  the  tube  or  in  a  uterine  cornu.    The  infundib- 

'  Of  6  such  operations,  conception  occurred  afterward  in  5-  I'fannenstiel, 
"  Ilandbuch  der  Gyn.,"  vol.  iii,  p.  488. 

2  "Medical   Record,"   1892,  (Jet.   i,  and  "  Centralbl.  f.  Gyn.,"  1897,  p.  421. 


Treatment  of  Ovarian  Tumors  505 

ulopelvic  ligament  is  cut  to  increase  the  mobility  of  the  ovary, 
but  its  attachments  at  the  hilus  are  undisturbed.  ^ 

'  Katsch,  "La  Gynecol.,"  Aug.,  1901  ;  Dudley,  "Jour.  Amer.  Med.  Assoc," 
Aug.  10,  1901  ;  Monprofit,  "  Centralbl.  f.  Gyn.,"  1901,  p.  984;  Halban,  "Verb, 
d.  deutschen  Ges.  f.  Gyn.,"  1901,  p.  619;  Amilo-Ro.xas,  "Archivio  di  Ostetr.  e 
Ginec,"  vol.  viii,  Nos.  5,  6;  Pfeiffer,  Diss.  Inaug.,  Tubingen,  1901  ;  Nicholson, 
"A  Review  of  the  Literature  of  Ovarian  Transportation,"  "Univ.  of  Penna.  Med. 
Bulletin,"  1902. 


PART  X. 

DISEASES  OF  THE  PELVIC  CONNECTIVE  TISSUE 
AND  OF  THE  PERITONEUM. 

The  pelvic  connective  tissue  may  be  divided  into — 

1.  The  loose,  cellular  tissue  acting  as  pads  or  cushions  filling 
the  pelvic  spaces  and  interposed  between  the  pelvic  viscera  to 
permit  their  mobility. 

2.  The  connective-tissue  investiture  of  the  pelvic  viscera 
under  the  serosa,  the  parametrium,  paracolpium,  paracystium, 
paraproctium,  analogous  to  the  subcutaneous  connective  tissue, 
but  sending  out  extensions  in  ligamentous  form  reinforced  by 
muscular  tissue,  as  the  cardinal  ligaments  of  the  uterus,  in  the 
bases  of  the  broad  ligaments  supporting  the  cervix  and  vaginal 
vaults,  the  uterosacral  Hgaments,  from  the  parametrium  around 
the  lateral  aspects  of  the  cervix  to  the  paraproctium,  the  utero- 
vesical  ligaments  from  the  parametrium  to  the  retrosymphyseal 
connective  tissue. 

3.  The  connective-tissue  sheaths  of  the  blood-vessels,  lym- 
phatics, and  nerves,  developed  in  the  bases  of  the  broad  ligaments 
into  strong  ligamentous  structures  supporting  the  cervix  and 
vaginal  vaults  and  regarded  as  the  main  factor  in  maintaining  the 
normal  uterine  position. 

4.  Membranous  extensions,  the  pelvic  fascia,  uniting  the  con- 
nective tissue  envelopes  of  the  pelvic  organs  with  the  pelvic 
walls,  fixing  them  and  all  the  pelvic  contents  in  their  normal 
position.  The  pelvic  fascia  is  divided  into  two  main  sheets — 
(i)  the  parietal,  lining  the  lateral  pelvic  walls  and  covering 
the  upper  aspect  of  the  pelvic  diaphragm,  and  (2)  the  perineal, 
covering  the  perineal  muscles  and  entering  into  the  composi- 
tion of  the  perineal  center  or  body.  The  connective-tissue 
sheaths  of  the  pelvic  muscles  are  offshoots  of  these  two  main 
divisions,  giving  to  the  pelvic  fascia  as  a  whole  its  complex  forma- 
tion. In  addition  to  the  two  main  horizontal  layers  of  the  pelvic 
fascia  there  are,  according  to  v.  Rosthorn,  three  perpendicular 
divisions  running  across  the  pelvis  transversely  dividing  imper- 
fectly the  vesical,  uterine,  and  rectal  spaces. 

In  addition  to  this  easily  recognizable  anatomical  arrange- 
ment of  the  pelvic  fascia  and  connective  tissue  there  are   finer 

506 


The  Pelvic  Connective  Tissue  507 

subdivisions  which  do  not  appear  upon  dissection,  but  which  are 
demonstrable  by  injection  experiments.  Thus,  if  fluid  is  injected 
between  the  peritoneal  layers  into  the  upper  part  of  the  broad 
ligament,  the  mesosalpinx,  the  upper  portion  of  the  broad  liga- 
ment is  distended,  the  fluid  appears  in  the  iliac  fossa  and  spreads 
downward  toward  Poupart's  ligament  and  upward  into  the 
mesocolon.  Injections  under  the  anterior  peritoneal  covering  of 
the  base  of  the  broad  ligament  result  in  an  infiltration  of  the 
paracystium,  the  connectiv^e  tissue  between  the  cervix  uteri  and 
bladder,  the  round  ligament  and  the  groin.  Injections  under  the 
posterior  peritoneal  covering  of  the  base  of  the  broad  ligament 
result  in  an  infiltration  of  the  posterior  portion  of  the  broad  liga- 
ment alone,  the  iliac  fossa,  the  mesocolon,  or  the  region  of 
Poupart's  ligament.  The  anterior  division  of  the  pelvis  is  not 
affected.  Injections  into  the  connective  tissue  of  the  lateral 
vaginal  vault  alongside  the  vaginal  portion  of  the  cervix  result  in 
infiltration  of  the  connective  tissue  under  the  mucous  membrane 
of  the  vaginal  vault,  the  paravesical  and  precervical  spaces,  and 
later  of  the  base  of  the  broad  ligament.  Injections  into  the 
anterior  vaginal  vault  cause  infiltration  of  the  precervical  and 
paravesical  connective  tissue,  into  the  posterior  vaginal  vault  infil- 
tration of  the  retrocervical  connective  tissue,  and  extending 
downward,  of  the  connective  tissue  between  the  x-agina  and  rectum 
and  to  either  side  of  the  latter. 

These  experiments  explain  in  part  the  extensions  in  various 
directions  of  a  pelvic  abscess. 

The  pelvic  connective  tissue  is  in  direct  communication  by 
continuity  with  that  of  the  external  surfaces  of  the  body  by  ex- 
tensions along  the  vessels  and  canals  that  leave  the  pelvis  and 
with  the  subperitoneal  connective  tissue  of  the  upper  abdomen 
mainly  along  the  great  blood-vessels  and  lymphatics,  the  meso- 
cecum  and  colon,  and  the  intra-abdominal  subperitoneal  fascia. 

The  arrangement  of  the  pelvic  peritoneum  is  too  well  under- 
stood to  require  extended  description.  Covering  all  the  pelvic 
viscera  and  structures  except  the  ovaries,  it  is  thrown  into  folds, 
elevations,  and  depressions  by  the  form  of  the  pelvic  organs  under 
it,  the  spaces  between  them,  and  the  ligaments  supporting  or  con- 
necting them. 

The  most  essential  anatomical  features  for  the  student  of  gyn- 
ecology to  remember  are  the  shallow  uterovesical  pouch  or  re- 
duplication ;  the  deeper  uterorectal  pouch  or  the  pouch  of 
Douglas,  with  the  uterosacral  ligaments  on  either  side  of  its 
upper  boundaries ;  the  elevation  of  the  peritoneum  over  the 
bladder  and  its  union  with  the  internal  surface  of  the  anterior 
abdominal  wall   at  such   a   level  that  a  considerable  space  is   left 


5o8       Pelvic  Connective  Tissue  and  Peritoneum 

above  the  symphysis,  in  which  an  incision  may  be  made  without 
opening  the  peritoneal  cavity.  The  greater  the  distention  of  the 
bladder,  the  higher  is  the  level  of  peritoneal  attachment  to  the 
anterior  abdominal  wall. 

Inflammation  of  the  Pelvic  Connective  Tissue. — Pelvic  cel- 
lulitis, or  parametritis,  is  of  puerperal  origin  in  more  than  two- 
thirds  of  the  cases.  It  is  always  due  to  an  infection.  Aside  from 
the  child-bearing  process,  the  introduction  of  foreign  bodies  into 
the  vagina,  such  as  pessaries,  syringe  nozzles,  sponges  to  prevent 
conception;  rough  and  unskilful  digital  examinations ;  operations 
upon  and  explorations  of  the  cervix  and  uterine  cavity  ;  the  mixed 
infection  of  a  gonorrhea  in  which  streptococci  and  staphylococci 
follow  the  gonococci ;  micro-organisms  settled  in  the  pelvic  con- 
nective tissue  from  the  bowel,  the  bladder,  and  the  blood ;  sup- 
puration of  intraligamentary  tumors,  and  extension  of  an  infec- 
tious inflammation  from  the  tubes  and  tiie  ovaries  are  causes  of 
pelvic  cellulitis.  Inflammations  of  apparently  spontaneous  or  pri- 
mary character,  as  for  example  in  young  girls  with  an  intact 
hymen  catching  cold  during  menstruation,  without  demonstrable 
source  of  infection,  are  explained  by  a  lessened  resisting  power  in 
the  pelvic  connective  tissue  and  an  immigration  of  micro-organ- 
isms from  the  lymphatics,  the  blood-current,  or  possibly  from 
the  bowel.  The  pathological  anatomy  and  terminations  are  the 
same  as  in  the  inflammation  of  puerperal  origin — edema,  exudate, 
resolution,  suppuration,  or  eventually  a  chronic  cirrhosis  and 
thickening  of  the  pelvic  connective  tissue.  The  situation  of  the 
inflammation  is  in  one  of  the  divisions  of  the  pelvic  connective 
tissue,  between  the  layers  of  the  broad  ligament,  in  the  paramet- 
rium, the  paracystium,  or  paraproctium.  The  probable  course 
of  suppuration  in  these  localities  has  already  been  indicated  in  the 
description  of  injection  experiments  in  the  pelvic  connective  tis- 
sue. If  suppuration  occurs  and  the  abscess  is  not  evacuated  hy 
an  early  incision,  spontaneous  rupture  is  likely  into  the  vaginal 
vault,  the  pelvic  viscera,  the  rectum,  through  the  abdominal  wall 
over  Poupart's  ligament  or  above  the  symphysis  and  possibly 
through  the  sciatic  foramen  in  the  gluteal  region,  through  the 
ischiorectal  fossa  in  the  perineal  region  alongside  the  anus, 
through  the  obturator  foramen  on  the  inner  side  of  the  thigh, 
through  the  crural  canal  on  the  anterior  surface  of  the  thigh,  and, 
rarest  of  all,  backward,  past  the  outer  edge  of  the  quadratus 
lumborum  through  the  skin  of  the  back. 

As  in  the  puerperium,  pelvic  cellulitis  is  very  frequently  asso- 
ciated with  pelvic  peritonitis. 

The  symptoms  are  general  and  local.  The  former  are  those 
of   infections  in  general — fever,  rapid  pulse,  prostration,  possibly 


Treatment  of  Pelvic  Cellulitis  509 

chills  and  pyemic  manifestations.  The  latter  are  intense  pain 
and  sensitiveness  at  first,  quite  rapidly  subsiding  if  resolution 
occurs,  and  often  diminishing  even  though  suppuration  fol- 
lows. There  is  irritability  of  the  bladder  or  bowel  if  the  inflam- 
mation involves  the  paracystium  or  paraproctium.  On  a  digital 
examination  there  is  at  first  a  boggy  feel  of  the  affected  edematous 
area,  followed  by  the  stone-like  hardness  of  a  cellulitic  exudate 
or  the  doughy  feel  of  suppuration.  The  situation  and  extension 
of  the  infiltration  may  make  the  diagnosis  plain  and  may  enable 
one  to  decide  definitely  that  he  is  dealing  with  a  pelvic  cellulitis 
alone  and  not  with  a  pelvic  peritonitis  or  a  combination  of  the 
two.  Thus,  in  a  retrocervical  cellulitis  the  inflammation  extends 
downward  between  the  vagina  and  rectum  far  below  the  lowest 
possible  level  of  Douglas's  pouch,  pushing  the  posterior  vaginal 
wall  forward  and  practically  obliterating  the  posterior  fornix.  In 
an  inflammation  of  the  paracystium  a  mass  is  felt  above  the  sym- 
physis, shading  off  laterally,  without  the  well-defined  lateral  iDor- 
ders  of  an  intrapelvic  tumor.  By  the  vagina  the  exudate  is  not  so 
plainly  appreciable ;  the  lateral  and  posterior  vaginal  fornices  are 
normal  to  the  sense  of  touch.  In  a  parametritis  extending  along 
the  base  of  the  broad  ligament,  the  mass  is  continuous  with  the 
cervix  on  the  affected  side,  extends  to  the  pelvic  wall,  and  is  felt 
above  Poupart's  ligament  as  a  hard,  infiltrated  area  extending 
within  the  anterior  superior  spine  of  the  ilium  to  the  iliac  fossa. 
Douglas's  pouch  is  free,  though  the  infiltrated  connective  tissue 
may  be  felt  embracing  the  posterior  surface  of  the  cervix.  It  is 
often  impossible,  however,  to  make  a  positive  differential  diagnosis 
between  pelvic  cellulitis  and  pelvic  peritonitis  without  an  explora- 
tory abdominal  section.  The  elaborate  tables  in  many  text-books 
drawing  sharply  defined  lines  between  the  two  are  misleading. 
In  case  of  doubt  an  abdominal  section  is  indicated.  If  the  sup- 
puration is  entirely  extraperitoneal,  the  abdomen  is  closed  and 
the  abscess  is  opened  in  the  most  appropriate  place — usually 
above  Poupart's  ligament,  often  through  the  vaginal  vault,  or  in 
both  places,  to  allow  a  through-and-through  drainage. 

Treatment. — Retrocervical  inflammation  and  suppuration  are 
treated  by  an  incision  in  the  posterior  vaginal  wall;  suppurative  in- 
flammation of  the  paracystium,  by  an  incision  above  the  symphysis. 
Counterdrainage  through  the  anterior  vaginal  vault  is  contraindi- 
cated  for  fear  of  injuring  the  bladder.  If  the  case  is  seen  late  and 
the  abscess  is  pointing  in  one  of  the  unusual  situations  already 
noted  (the  thigh,  the  perineum,  and  the  back),  the  incision  may  be 
made  there.  Prolonged  drainage  of  the  abscess  cavity  by  a  rubber 
tube  and  daily  irrigation  are  usually  necessary.  Pelvic  cellulitis 
of  non-puerperal  origin  is  more  likely  to  end  in  resolution  than 


5IO       Pelvic   Connective  Tissue  and  Peritoneum 

is  puerperal  inflammation.  Time  should  be  allowed,  therefore, 
for  a  spontaneous  cure.  Rest  in  bed,  ice-bags  or  the  ice-water 
coil  over  the  groin  or  h}'pogastrium,  hot  vaginal  douches  twice 
daily,  a  soft  diet  and  laxatives  are  ordered.  A  persistence  of  fever 
and  of  the  local  symptoms  of  inflammation  for  more  than  a  week 
ordinarily  indicates  operative  interference.  If  the  acute  symptoms 
subside,  the  exudate  organizes  and  is  not  absorbed,  there  is  fixa- 
tion of  the  pelvic  organs,  pain  on  movement,  jolt,  or  jar,  irrita- 
bihty  of  the  bladder,  irritation  or  partial  obstruction  of  the  rectum, 
chronic  congestion  of  the  pelvic  viscera,  and  disturbances  of  men- 
struation. The  pelvic  exudate  is  felt  on  a  combined  examination, 
most  often  in  the  parametrium,  next  most  frequently  in  the  retro- 
cervical  tissues,  but  possibly  in  any  of  the  divisions  of  the  pelvic 
connective  tissue. 

TJie  treatment  of  organized  celbditic  exudate  is  borogljxerid 
tampons  in  the  vagina  ;  the  application  of  heat  to  the  whole  pelvic 
region  by  sitz-baths  or  special  apparatuses  like  the  heat  chambers 
for  inflamed  and  rheumatic  joints;^  pressure  by  bags  of  shot  or 
mercury  on  the  hypogastrium,  and  a  distended  colpeurynter  in 
the  vagina  or  rectum  ;  abdominal  massage  and  Swedish  exercise. 
Surgical  intervention  is  occasionally  required  to  sever  bands  of 
organized  exudate  or  the  thickened  sacro-uterine  ligaments. 

By  chronic  cellulitis  is  understood  a  condition  not  necessarily 
related  to  the  infectious  acute  cellulitis  just  described.  There  may 
be  no  history  of  fever,  acute  pain,  or  of  infection.  It  is  rather  a 
chronic  congestion  than  an  inflammation,  and  in  its  earlier  stages 
is  ahvays  associated  with  chronic  metritis  and  endometritis.  In 
short,  it  is  but  part  of  a  general  pelvic  congestion,  and  scarcely 
deserves  the  distinctive  name  of  an  entity  among  the  pelvic  diseases. 
It  usually  follows  childbirth,  but  is  only  demonstrable  some  weeks 
or  months  afterward.  It  may  be  due  to  any  of  the  causes  of 
chronic  pelvic  congestion.  It  has  therefore  the  same  causes 
as  a  chronic  metritis  and  endometritis.  There  are  the  usual  path- 
ological changes  of  chronically  congested  connective  tissue — 
hyperemia,  overgrowth,  and  an  ultimate  shrinkage.  The  hyper- 
emic  stage  is  not  demonstrable  except  in  the  associated  hyperemia 
of  the  uterus,  the  endometrium,  and  the  uterine  adnexa.  In  the 
stage  of  overgrowth  the  pelvic  connective  tissue  is  thickened  and 
becomes  inelastic.  These  physical  conditions  are  most  marked, 
as  might  be  expected,  wliere  the  pelvic  connective  tissue  is 
originally  thickest  and  best  developed — namely,  in  the  utero- 
sacral  ligaments  and  in  the  bases  of  the  broad  ligament  (the  car- 
dinal ligaments  of  the  uterus).  The  result  is  a  certain  amount  of 
fixation  and  possibly  some  displacement  of  the  uterus.      For  ex- 

1  Polano,  "  Centralbl.  f.  Gyn.,"  1901,  No.  30. 


Injuries  of  the  Pelvic   Connective  Tissue         511 

ample,  thick  and  inelastic  uterosacral  ligaments  are  often  found 
with  anteflexion  of  the  uterus.  The  thickened  and  stiffened  liga- 
ments are  sensitive.  Hence  movements  of  the  pelvic  viscera, 
coitus,  defecation,  walking,  jolts  or  jars  of  any  kind  may  be 
painful.  Many  local  s\-mptoms  and  reflex  neuroses  are  ascribed 
to  chronic  cellulitis,  but  they  are  expressions  of  the  general  pelvic 
congestion  and  are  referable  rather  to  the  metrids  and  endometri- 
ds  than  to  the  cellulitis.  On  digital  examination  the  thickened 
bands  of  connective  tissue  are  plainly  felt,  occupying  the  sit- 
uation and  following  the  course  of  the  cardinal  uterine  liga- 
ments and  of  the  uterosacral  ligaments.  Sweeping  the  finger-tip 
across  them  causes  acute  pain.  It  is  easy  to  mistake  bands  of 
peritoneal  adhesions  for  the  thickened  ligaments,  but  a  rectal  as 
well  as  a  vaginal  examination  should  enable  one  to  differentiate 
between  the  two. 

Tlic  treatment  of  this  form  of  cellulitis  is  the  removal  of  all 
causes  of  pelvic  congestion,  the  repair  of  injuries,  curettage,  and 
for  the  hyperplasia  of  the  comiective  tissue  itself,  a  prolonged 
course  of  glycerin  and  ichthyol  lamb's-wool  tampons  renewed 
every  other  day  and  packed  tightly  enough  to  exert  consider- 
able pressure,  with  an  apphcation  of  iodin  to  the  vaginal  vault 
about  once  a  week.  Abdominal  massage  and  the  Swedish 
movements  designed  to  exercise  the  pelvic  muscles  and  ligaments 
are  most  helpful,  in  addition  to  the  local  treatment.  Of  all  pel- 
vic conditions,  chronic  cellulitis  ought  to  be,  and  no  doubt  is,  the 
one  most  benefited  by  the  Thure  Brandt  system  of  pelvic  mas- 
sage by  intravaginal  manipulations,  but  the  method  is  so  objec- 
tionable that  the  author  has  never  favored  it  as  a  treatment  to  be 
carried  out  by  the  physician.  ^ 

The  ultimate  stage  of  chronic  cellulitis  is  shrinkage  of  the 
indurated  pelvic  connective  tissue,  strangulation  of  the  blood-  and 
nerve-supply  which  passes  through  it  to  the  genital  organs,  and 
a  consequent  atrophy,  with  diminution  in  the  size  of  the  uterus, 
amenorrhea,  precocious  menopause,  and  contraction  of  the 
vagina.  Hence  this  form  of  cellulitis  is  called  the  atrophic.  If 
far  advanced  it  is  incurable. 

Injuries  of  the  pelvic  connective  tissue,  aside  from  the 
child-bearing  process,  have  the  same  causes  as  injuries  of  the 
vagina  and  uterus  (pp.  145,  314),  with  which  they  are  almost 
always  associated,  though  it  is  conceivable  that  without  demon- 
strable injury  of  the  vaginal  mucous  membrane  or  skin  of  the 
vulva  a  trauma  might  be  transmitted  to  the  subjacent  connective 
tissue.     The  possible  results  are  hemorrhage,  infection,  and  scar- 

1  For  some  time  I  referred  patients  to  a  masseuse  who  had  taken  a  course  in 
Copenhagen  and  was  well  versed  in  the  system,  but  the  results  were  not  satisfactory. 


512       Pelvic  Connective  Tissue  and  Peritoneum 

tissue  development.  Frank  hemorrhage  is  managed  on  general 
surgical  principles  by  pressure  with  a  tampon  or  the  ligation  of 
bleeding  vessels.  Interstitial  hemorrhage  or  pelvic  hematoma  i 
deserves  special  consideration.  Intraperitoneal  and  extraperi- 
toneal pelvic  hemorrhages  were  first  differentiated  by  Huguier 
(1851).  The  latter  are  comparatively  rare,  occurring  not  one- 
tenth  as  often  as  the  former.  The  situation  of  the  effusion  is 
either  above  or  below  the  pelvic  diaphragm.  The  latter  cases 
are  considered  in  connection  with  the  diseases  of  the  vagina  and 
vulva.  The  interstitial  hemorrhages  above  the  pelvic  dia- 
phragm and  below  the  peritoneum  may  occupy  one  of  three 
situations:  (i)  precervical,  from  rupture  of  the  veins  in  the 
plexus  at  the  base  of  the  bladder;  (2)  para-uterine,  from  the 
vessels  of  the  broad  ligament,  either  those  at  its  base,  the  utero- 
vaginal plexus,  or  those  in  the  upper  portion,  the  pampiniform 
plexus ;  (3)  retrocervical  or  retrovaginal,  from  the  hemorrhoidal 
plexus.  There  may  be  an  extension  of  the  effusion  from  one 
locality  to  another;  thus,  a  hematoma  in  one  broad  ligament  has 
extended  around  the  cervix  to  the  other  broad  ligament.  There 
is  a  tendency  for  the  extravasation  to  follow  the  course  of  injec- 
tions into  the  pelvic  connective  tissue  already  described. 

Pelvic  hematoma  is  usually  associated  with  child-bearing ;  it 
may  have  its  origin  in  tubal  or  broad  ligament  gestation.  Aside 
from  the  child-bearing  process,  the  cause  may  be  found  in  trau- 
matism, strains,  acute  congestion,  diseases  of  the  blood-vessels, 
as  in  nephritis  and  syphilis,  and  in  varices  of  the  pelvic  veins, 
most  often  in  those  of  the  pampiniform  plexus.  ^  Except  in 
association  with  child-bearing  the  accident  is  usually  one  of 
middle  or  advanced  age. 

The  diagnosis  of  interstitial  pelvic  hemorrhage  should  not  be 
very  difficult :  Following  one  of  the  causes  enumerated,  a  sudden 
violent  pelvic  pain,  associated  with  the  symptoms  of  internal 
bleeding  if  the  hemorrhage  is  not  soon  checked  by  the  ana- 
tomical limitations  of  the  effusion  ;  the  appearance  of  a  tumor 
limited  to  the  pelvic  connective  tissue  in  one  of  the  three  situations 
described ;  a  displacement  of  the  uterus  away  from,  the  hematoma  ; 
the  intimate  association  of  the  mass  with  the  uterine  body  or 
cervix  ;  the  gradual  change  in  the  consistency  of  the  tumor,  as 

'  In  common  with  the  majority  of  writers,  the  author  uses  the  words  hematoma 
for  interstitial  pelvic  hemorrhage  and  hematocele  for  intraperitoneal  hemorrhage. 

2  The  author  had  charge  of  a  case  in  the  Philadelphia  Hospital :  An  elderly 
woman,  while  walking  across  a  court-yard,  fell  to  the  ground  and  became  unconscious. 
On  examination,  signs  of  internal  hemorrhage  were  manifest,  and  a  pelvic  exami- 
nation revealed  free  fluid  in  the  abdomen.  An  immediate  section  demonstrated  a  rup- 
ture of  the  ])ampiniform  plexus,  a  pelvic  hematoma,  rupture  of  the  posterior  leaf  of  the 
broad  ligament,  and  intraperitoneal  bleeding.      The  woman  recovered. 


Injuries  of  the  Pelvic   Connective  Tissue        513 

the  blood  clots,  and  the  absence  of  fever  or  other  signs  of  inflam- 
mation should  indicate  with  sufficient  distinctness  the  nature  of 
the  accident.  The  greatest  difficulty  in  the  diagnosis  of  a 
pelvic  hematoma  is  its  differentiation  from  a  pelvic  hematocele. 
The  difficulty  is  increased  by  the  fact  that  the  two  may  be  asso- 
ciated. The  following  symptoms  are  useful  in  the  differential 
diagnosis :  The  effusion  is  limited  to  certain  areas  and  in 
amount  in  pelvic  hematoma ;  not  at  first  necessarily  so  in  pelvic 
hematocele  ;  there  is  an  absence  of  peritonitic  symptoms  in  hema- 
toma ;  they  are  present  in  hematocele.  The  direction  of  the 
effusion  is  downward  in  hematoma,  upward  in  hematocele.  In 
hematoma  there  is  a  tendency  to  recurrence  of  the  hemorrhage, 
and  successive  increments  in  the  size  of  the  tumor,  which  is  not 
the  case  in  hematocele.  The  tumor  slowly  reaches  its  maximum 
size  in  hematoma,  quickly  in  hematocele.  A  hematocele  almost 
always  occupies  in  part  at  least  Douglas's  pouch,  without  extend- 
ing downward  behind  the  posterior  vaginal  wall ;  a  retrocervi- 
cal  hematoma  burrows  downward  between  the  vagina  and  the 
rectum.  Hematoma  in  the  vast  majority  of  cases  is  completely 
absorbed  and  leaves  no  trace  behind  it ;  hematocele  is  always 
followed  by  peritoneal  adhesions  even  if  the  blood  is  completely 
absorbed.  The  absorption  of  the  blood  is  accomplished  slowly 
in  hematoma,  much  more  quickly  in  hematocele. 

The  terminations  of  a  hematoma  are :  absorption,  w' hich  almost 
always  occurs ;  rupture  into  the  peritoneal  cavity,  the  vagina,  or 
rectum  ;  and  suppuration. 

The  treatment  should  usually  be  abstention  from  all  active  in- 
terference,^ rest  in  bed,  application  of  cold  over  the  site  of  the 
effusion  until  there  is  no  further  increase  in  the  size  of  the -tu- 
mor, and  opium  to  allay  the  pain  and  to  promote  perfect  rest. 
Later,  means  to  favor  absorption  may  be  recommended  ;  vag- 
inal douches,  iodin  over  the  groins  or  to  the  vaginal  vaults  ; 
cautious  abdominal  massage,  and  the  faradic  electric  current. 
Weeks  and  months  may  be  required  for  the  complete  absorption 
of  a  hematoma.  If  the  tumor  is  very  large,  if  a  spontaneous 
rupture  is  feared,  if  there  are  signs  of  infection  and  inflammation, 
operative  interference  is  indicated.  Precervical  and  retrocervical 
effusions  are  best  opened  through  the  vaginal  vaults.  The  cavity 
is  carefully  cleansed  of  all  blood-clots,  is  irrigated  and  drained  from 
day  to  day,  until  it  is  gradually  obliterated.  Cases  of  parametritic 
hematoma  between  the  layers  of  the  broad  ligament  may  be 
treated  in  the  same  way,  but  not  infrequently  the  vaginal  incision 
is  found  inadequate.      Deaths  have  occurred  from  decomposing 

1  Thorn,  in  34  cases,  found  operative  interference  necessary  only  once  ;    "  Wien. 
med.  Wochenschr.,"  No.  10,  1895. 
33 


514       Pelvic   Connective  Tissue  and  Peritoneum 

blood-clots  left  behind  after  a  colpotomy.  Abdominal  section 
or  an  extraperitoneal  incision  above  Poupart's  ligament  gives 
better  access  to  the  tumor  cavity.  In  an  abdominal  section 
it  may  be  possible  to  incise  the  vaginal  vault  from  above  for  the 
purpose  of  drainage  after  the  tumor  cavity  has  been  thoroughly 
emptied  of  all  liquid  and  clotted  blood,  finally  sewing  the  layers 
of  the  broad  ligament  together  again  over  the  site  of  the  hema- 
toma. In  an  inguinal  section  it  is  often  an  advantage  to  establish 
through-and-through  drainage  by  a  rubber  tube  inserted  in  the 
opening  over  Poupart's  ligament  and  led  out  through  a  puncture 
in  the  vaginal  vault  as  close  to  the  cervix  as  possible. 

Neoplasms  of  the  Pelvic  Connective  Tissue. — Fibromyomata, 
springing  usually  from  the  ovarian  or  the  round  ligaments, 
are  the  commonest  growths  of  the  pelvic  connective  ti.ssue, 
but  they  are  comparatively  rare.  Sanger,  in  1883,  collected 
1 1  cases  of  fibromyomata  of  the  broad  ligament,  1 2  of  the 
round  ligament;  Kreckels,  in  1896,  collected  45  such  tumors; 
and  V.  Rosthorn,  51.^  It  is  certain  that  the  growth  does  not 
spring  from  the  uterus  or  ovary  only  if  it  can  be  clearly  demon- 
strated that  no  connection  exists  between  the  tumor  and  these 
organs  except  the  normal  anatomical  structures.  Thus,  a  fibro- 
myoma  of  the  ovarian  ligament  should  be  connected  with  both 
the  ovary  and  the  uterus  by  an  extension  of  the  ligament  from 
the  tumor  and  by  the  broad  ligament  investiture  common  to  all 
three,  but  there  should  be  no  new-formed  pedicle,  and  both 
ovary  and  uterus  should  be  distinct  from  the  tumor  (Fig.  442). 
Tumors  of  the  round  ligament  are  most  likely  to  be  peduncu- 
lated. Those  of  the  ovarian  ligament  may  be  also.  Connective- 
tissue  growths  originating  in  the  base  of  the  broad  ligament 
remain  intraligamentary.  The  symptoms,  the  clinical  history, 
and  the  degenerations  of  these  growths  are  the  same  as  those  of 
intraligamentary  uterine  fibroids. 

The  differential  diagnosis  of  fibroids  of  the  pelvic  connective 
tissue  from  uterine  and  ovarian  tumors  is  practically  impossible 
until  the  abdomen  is  opened.  If  they  grow  from  the  base  of  the 
broad  ligament,  they  are  naturally  taken  for  cervical  intraliga- 
mentary myomata  ;  if  from  the  upper  portion  of  the  broad  liga- 
ment, for  tumors  of  ovarian  origin  or  for  subperitoneal  fibroids 
of  the  uterus.  Fibromyomata  of  the  round  ligament  originating 
in  the  pelvis  and  extending  into  the  inguinal  canal  would  alone 
present  distinctive  features  by  the  peculiarity  of  their  course  of 
growth  and  their  situation. 

If  the  tumor  has  reached  a  considerable  size,  if  it  causes  pres- 
sure symptoms,  if  the  rate  of  growth  becomes  suddenly  rapid 
1  "  Handbuch  der  Gyn.,"  vol.  iii,  2,  p.  157. 


Neoplasms  of  the   Pelvic   Connective  Tissue     515 

instead  of  beini;  extremely  slow,  which  is  the  rule,  operative 
interference  is  indicated.  The  removal  of  a  pedunculated  tumor 
presents  no  difficulty  ;  ligation  of  the  pedicle  and  excision  are 
alone  necessary.  Intraligamentary  growths  are  removed  in 
the  same  way  as  intraligamentary  fibroids  of  the  uterus,  intra- 
ligamentary  tumors  of  the  ovary,  and  parovarian  cysts.  The 
ovarian  artery  is  ligated  in  two  places,  the  free  edge  of  the 
broad    ligament    is   cut   between   the   ligatures,    or    an    incision 


Fig.  442. — Myoma  of  the  ovarian  ligament:    T,  Tube;    O,  ovary;   L,  broad  ligament. 


is  made  over  the  anterior  face  of  the  broad  ligament,  the 
capsule  of  the  tumor  is  incised,  and  it  is  peeled  out  of  its 
bed,  often  with  surprising  ease.  If  the  tumor  has  grown  up- 
ward into  the  mesocolon  on  either  side,  the  control  of  hemor- 
rhage is  difficult  and  numerous  vessels  must  be  ligated;  if  down- 
ward, the  ureter  is  endangered,  in  its  removal ;  the  precautions 
necessary  to  avoid  such  an  accident,  and  the  treatment  of  the  bed 
of  the  enucleated  tumor,  have  already  been  described. 


5i6       Pelvic  Connective  Tissue  and  Peritoneum 


Other  tumors  having  their  origin  in  the  pelvic  connective  tissue 
are  sarcomata,  carcinomata,  lipomata.i  and  dermoids.  In  i6  re- 
ported cases  of  the  last  named,  the  greater  number  (5)  were  situ- 
ated between  the  rectum  and  the  sacrum.  They  have  the  same 
structure  and  peculiarities  as  dermoids  in  other  portions  of  the 
body,  and  do  not  display  the  compHcated  embryonal  development 
seen  in  the  so-called  dermoids  or  ovulogenous  tumors  of  the 
ovary  unless  they  are  derived  from  an  accessory  ovary.  ^ 

Sanger's  proposition  to   remove  dermoids  as  well  as   other 


Fig.  443.  — Transverse  perineot- 
omy :  a,  Vagina  ;  b,  levator  ani  muscle ; 
c,  ischiorectal  fossa  ;  d,  rectum  (Zucker- 
kandl). 


Fig.  444. — Sagittal  perineotomy  :  a. 
Tuber  ischii ;  h,  levator  ani  muscle  and 
pelvic  fascia ;  c,  anus ;  d,  ischiorectal  fossa  ; 
e,  gluteus  maximus  muscle  (Hegar-Sanger). 


tumors  of  the  pelvic  connective  tissue  by  perineal  section  is 
worthy  of  a  more  extended  trial.  The  operation  is  most  ap- 
propriate for  the  removal  of  tumors  situated  low  within  the  sub- 
peritoneal pelvic  cavity. 

Carcinomata  in  the  parametrium,  if  they  are  primary,  origi- 
nate in  the  remnants  of  the  Wolffian  body.  ^  They  may  be  sec- 
ondary or  metastatic. 

Echinococcus  cysts  of  the  pelvic  connective  tissue  are  very  rarely 
observed  in  America.*    In  other  parts  of  the  world,  notably  in  cer- 

1  Sanger  collected  7  cases  of  lipomata ;  von  Rosthorn,  4  of  sarcomata  (<?/.  cit., 
p.  168). 

2  Seitz  reports  a  number  of  such  cases  ("  Volkmann's  klin.  Vortr.,"  No.  286). 

^  Heinsius,  "  Carcinombildung  im  Beckenbindegewebe,"  "Zeitschr.  f.  Geb.  u. 
Gyn.,"  Bd.  xlv,  H.  2. 

■*  The  author  has  seen  one  case  in  fifteen  years. 


Varices  or  Varicocele  of  the  Broad  Ligament     5 1 7 

tain  districts  of  Germany  (Breslau,  Mecklenburg^),  tliey  are  more 
common.  The  retrocervical  connective  tissue  and  the  paraproc- 
tium  are  the  favorite  seats  of  the  parasitic  growths.  The  tumor 
varies  in  size  from  that  of  an  orange  to  that  of  a  cocoanut.  The 
rate  of  growth  is  extremely  slow.  The  diagnosis  is  made  before 
operation  by  the  passage  of  cyst  membranes,  hooklets,  and  even 
of  entire  cysts  spontaneously  from  the  rectum,  bladder,  or  vagina, 
through  ulcerative  perforations,  or  by  obtaining  the  same  struc- 
tures through  an  exploratory  puncture  or  incision. 

The  treatment  is  the  removal  of  the  entire  cystic  mass  by 
vaginal  section,  if  possible.  If  the  abdomen  is  opened,  it  may  be 
possible  to  enucleate  the  entire  mass  as  in  the  case  of  intraliga- 
mentary  tumors  ;  but  for  fear  of  implantation  metastases  it  is  safer 
to  sew  the  main  cyst-wall  to  the  abdominal  wall,  to  evacuate  its 


Fig.  445. — Interrupted  ligatures  inserted  at  short  intervals  by  means  of  long-handled 
curved  needle  (from  Reed's  "Gynecology"). 


interior  as  well  as  possible  and  to  establish  through-and-through 
drainage  by  puncturing  the  vaginal  vault.  ^ 

Actinomycosis  of  the  pelvic  connective  tissue  has  been  reported 
by  V.  Hacker  and  by  Sanger.  ^  The  physical  signs  and  clinical 
history  suggest  a  pelvic  abscess.  The  diagnosis  is  made  by  the 
microscopical  examination  of  the  purulent  discharge  through  a 
fistulous  opening  or  incision  and  the  discovery  of  the  character- 
istic fungus. 

Varices  or  varicocele  of  the  broad  ligament  are  quite  frequently 
observed  in  connection  with  pelvic  conditions  determining  a 
chronic  congestion  of  the  pelvic  vessels  such  as  fibroids,  uterine 
displacements,  chronic  inflammatory  conditions  of  the  uterine 
appendages,  obstructed  circulation  in  heart  and  liver  disease.     A 

1  Mayer,  Inaug.  Diss.,  Giessen,  1900.      Good  history  and  bibliography. 
^  Von  Rosthorn  i^op.  cit.)  gives  these  as  the  only  recorded  cases. 


5i8       Pelvic  Connective  Tissue  and  Peritoneum 

sedentary  life,  constipation,  the  long-continued  working  of  a  sew- 
ing machine,  deterioration  of  the  general  health,  and  disease  of 
the  blood-vessel  walls  have  been  recognized  as  causes.  The  veins 
of  the  left  broad  ligament  are  more  often  and  more  seriously  af- 
fected than  those  of  the  right,  on  account  of  the  manner  in  which 
the  efferent  venous  trunk  empties  into  the  left  renal  vein  at  a  right 
angle  to  the  blood-current.  The  veins  of  the  pampiniform  plexus 
are  most  often  the  seat  of  the  varicosities. 

The  symptoms  of  varices  of  the  broad  ligament  are  usually 
masked  by  those  of  associated  and  more  serious  conditions. 
They  are  a  sense  of  heaviness  and  fullness,  and  a  dull  aching 
pain  in  the  pelvic  cavity,  relieved  by  the  recumbent  posture,  but 
returning  as  soon  as  the  individual  stands  erect,  and  aggravated 
by  exertion.     It  is  claimed  that  the  enlarged  veins  may  be  felt  in 


Fig.  446. — Division  of  the  veins  (from  Reed's  "Gynecology"). 


a  combined  examination,  but  such  delicacy  of  tactile  sense  is  not 
often  attainable.  1  The  dilated  veins  may  rupture  with  a  danger- 
ous, if  not  a  fatal,  intraperitoneal  hemorrhage. 

The  treatment  is  the  removal  of  the  cause  of  the  pelvic  con- 
gestion, if  possible ;  improvement  of  the  general  health ;  regulated 
exercises,  baths,  massage,  and  the  internal  administration  of 
hydrastinin.  If  the  condition  is  discovered  after  the  abdomen 
has  been  opened,  it  may  be  radically  cured  by  the  ligation  of  the 
pampiniform  plexus  in  sections  and  the  exsection  of  the  veins 
between  the  ligatures. 

Phleboliths  are  calcified  thrombi  in  the  dilated  pelvic  veins. 
They  vary  in  size  and  shape.  They  have  been  described  as  the 
size  of  a  pea  or  of  a  spindle-shaped  body  almost  two  inches  long 

^  The  author  has  operated  upon  a  number  of  cases  by  serial  ligature  and  exsec- 
tion of  the  pampiniform  plexus,  but  has  not  made  a  positive  diagnosis  in  a  single  one 
before  the  abdomen  was  opened. 


Pelvic  Peritonitis  519 

and  a  third  of  an  inch  thick  in  the  middle  (4.5  cm.  X  i  cm.).i 
They  can  be  felt  in  a  bimanual  examination,  especially  if  they  are 
in  the  veins  of  the  uterovaginal  plexus.  They  may  be  removed 
in  the  course  of  an  operation  undertaken  for  some  other  purpose, 
but  do  not  of  themselves  justify  operative  interference. 

Pelvic  peritonitis  is  most  often  secondary  to  salpingitis.  It 
may  follow  regurgitation  through  the  tubes  of  fluid  injected  into 
the  uterus,  or  of  lochial  discharge;  inflammation  of  the  ovaries; 
cellulitis ;  septic  cystitis ;  metritis ;  perforation  of  the  uterus  ; 
perityphlitis;  and  appendicitis. 

Acute  pelvic  peritonitis  is  manifested  by  sharp  pelvic  pain, 
tympany,  tenderness  over  the  lower  abdomen,  fixation  of  the  ab- 
dominal muscles,  exudate  occupying  varying  areas  of  the  intra- 
peritoneal pelvic  cavity,  fever,  rapid  pulse,  constipation,  nausea, 
and  vomiting.  The  inflammation  may  subside,  the  pelvic  ex- 
udate be  absorbed,  and  no  trace  of  the  inflammation  remain  ; 
but  more  commonly  the  exudate  is  organized  into  peritoneal  ad- 
hesions binding  the  uterus  to  the  rectum,  the  tubes  and  ovaries 
together  and  to  the  bowel.  If  the  infection  is  virulent  or  the 
resisting  power  of  tissues  low,  suppuration  follows  and  a  pelvic 
abscess  results,  opening  usually  into  the  bowel,  unless  the  pus  is 
evacuated  by  surgical  intervention  before  the  intestinal  coat  is 
perforated. 

The  treatment  of  acute  pelvic  peritonitis  is  rest  in  bed,  an  ice- 
coil  over  the  lower  abdomen,  a  saline  purge,  and  after  a  few 
days  hot  vaginal  douches  (a  gallon  of  water  at  120°)  twice  or 
oftener  a  day  to  promote  resolution  and  diminish  congestion. 
Opium  should  not  be  administered  if  it  can  be  avoided.  The 
pain  is  best  controlled  by  heroin  in  doses  of  ^  of  a  grain.  In  an 
adynamic  condition  of  the  patient,  alcohol,  digitalis,  and  strychnia 
are  indicated.  If  symptoms  of  inflammation  persist  for  many  days, 
associated  with  the  physical  signs  of  exudate,  fixation  of  the 
pelvic  organs,  and  an  irregular  temperature,  suppuration  has 
probably  occurred.  Abdominal  section  or  colpotomy  is  conse- 
quently indicated.  The  choice  between  the  two  is  governed 
mainly  by  the  site  of  the  inflammatory  mass,  and  the  patient's 
general  condition.  If  the  latter  is  bad,  the  vaginal  operation  is 
the  safer  of  the  two.  If  the  exudate  or  abscess  is  confined  to 
Douglas's  pouch,  a  posterior  colpotomy  is  most  appropriate. 
For  example,  the  posterior  uterine  wall  is  not  infrequently  per- 
forated in  an  attempt  to  induce  abortion.  Suppuration  often 
follows.  If  the  abscess  is  walled  off  and  the  suppuration  does 
not  extend  upward  into  the  general  peritoneal  cavity,  a  vaginal  sec- 
tion with  drainage  of  the  cavity  by  a  T-shaped  rubber  tube  is  very 
1  Zinke,  in  Reed's  "Text-Book  of  Gynecology, "  p.  683,  1901. 


520       Pelvic  Connective  Tissue  and  Peritoneum 

satisfactory.  If  the  wiiole  pelvis  is  involved,  if  the  tubes  and 
ovaries  are  affected,  an  abdominal  section,  with  subsequent  drain- 
age through  the  vagina  or  through  the  abdominal  wound  by- 
gauze  and  a  glass  tube  combined,  is  much  more  successful.  An 
unhealthy  condition  or  actual  perforation  of  the  bowel-wall 
should  be  suspected  and  looked  for  in  all  cases  of  pelvic 
abscess.  The  discovery  of  this  condition  naturally  necessitates 
drainage.  No  attempt,  as  a  rule,  should  be  made  to  close  the 
opening  in  the  bowel  unless  the  hole  is  small  and  the  surround- 
ing bowel-wall  is  healthier  than  is  usually  the  case.  Abdominal 
drainage  by  tube  and  gauze,  with  daily  irrigation  of  the  pelvis 
after  the  third  day,  results  in  a  spontaneous  closure  of  the  fistula 
in  the  majority  of  cases. 

The  treatment  of  organized  pelvic  adhesions  is  considered  in 
connection  with  displacements  of  the  uterus  and  salpingitis. 

Pelvic  hematocele  is  an  intraperitoneal  and  encapsulated 
effusion  of  blood.  According  to  its  situation  it  is  a  retro- uterine, 
ante-uterine,  supra-uterine,  or  peri-uterine  (lateral)  hematocele. 
There  may  be  a  combination  of  these  varieties.  The  commonest 
cause  by  far  is  a  tubal  abortion.  Recent  investigations  give  a 
frequency  of  this  cause  from  60  to  95  per  cent.  It  is  safe  to  say 
that  at  least  two-thirds  of  all  cases  are  traceable  to  tubal  gesta- 
tion. Other  causes  are  bleeding  from  the  tubes  and  ovaries  at 
the  menstrual  periods ;  regurgitation  of  blood  in  gynatresia ; 
rupture  of  a  pelvic  hematoma  through  the  peritoneum,  usually 
the  posterior  layer  of  the  broad  ligament ;  traumatism,  as  a  vio- 
lent coitus,  or  rupture  of  a  blood-vessel  in  a  gynecological  opera- 
tion ;  hemorrhagic  salpingitis  in  association  with  systemic  dis- 
eases, or  obstructed  pelvic  circulation  ;  malignant  neoplasms  of 
the  pelvis,  and  a  secondary  hemorrhage  following  operations  on 
the  pelvic  organs.  The  effusion  of  blood  into  the  pelvis  is  usu- 
ally the  primary  occurrence  ;  its  encapsulation  by  peritoneal  ad- 
hesions, the  secondary. 

The  symptoms  of  hematocele  are  sudden  appearance  of  pelvic 
pain,  fever  (often  to  a  great  height),  nausea  and  vomiting,  tym- 
pany, a  feeling  as  though  the  bladder  and  bowels  must  be  evacu- 
ated, though  the  patient  uniformly  experiences  difficulty  in  evacu- 
ating feces  and  is  often  unable  to  empty  her  bladder  ;  the  signs 
of  internal  hemorrhage  if  the  effusion  of  blood  is  not  quickly  lim- 
ited and  on  pelvic  examination  a  tumor  in  the  pelvic  cavity,  at  first 
vvith  the  characteristics  of  free  fluid  in  the  abdomen,  later  a  cystic 
swelling,  or,  if  the  blood  clots,  a  solid  mass,  occupying  one  of 
the  situations  already  mentioned  or  completely  filling  the  pelvic 
cavity. 

The  terminations  of  a  hematocele  are  complete  absorption, 


Pelvic  Hematocele  521 

usually  with  persistence  of  peritoneal  adhesions  ;  recurrent  hem- 
orrhages with  successive  enlargements  of  the  tumor ;  persistence 
of  the  encapsulated  accumulation  of  blood  for  months ;  evacua- 
tion of  the  blood  through  the  bowel,  bladder,  or  vagina  ;  suppu- 
ration and  the  formation  of  a  pelvic  abscess  ;  persistence  of  the 
serum  of  the  blood,  and  the  formation  of  a  cystic  tumor. 

The  treatment  is  expectant  if  the  effusion  of  blood  is  small 
in  amount  and  soon  shows  symptoms  in  its  diminishing  size  of 
rapid  absorption.  If  the  process  of  absorption  is  very  slow, 
promising  to  require  months  for  the  complete  disappearance  of 
the  tumor  ;  if  there  is  a  recurrent  hemorrhage,  signs  of  suppu- 
ration, severe  local  disturbance,  any  symptoms  indicating  tubal 
gestation  as  the  probable  cause  of  the  hematocele,  the  operative 
treatment  is  the  safer  and  more  successful.  Posterior  or  anterior 
colpotomy  may  suffice  if  the  blood  is  limited  to  Douglas's 
pouch  or  the  uterovesical  reduplication  of  the  peritoneum. 
Usually  an  abdominal  section  is  more  satisfactory,  giving  a  clearer 
view  of  the  origin  of  the  bleeding,  a  greater  security  against  its 
recurrence,  a  better  chance  to  evacuate  all  liquid  and  clotted 
blood,  and  not  necessitating  drainage  as  a  rule,  unless  there  are 
signs  of  an  unhealthy  condition  of  the  bowel-wall,  with  threat- 
ened perforation,  or  suppuration  of  the  hematocele.  Colpotomy 
should  be  followed  by  drainage. 


PART  XI. 
DISEASES  OF  THE  URINARY  TRACT. 

Anatomy. — The  kidney  in  the  female  deserves  no  special 
anatomical  consideration.  Its  distinctive  peculiarity  is  the  ten- 
dency to  abnormal  mobility  on  the  right  side.  About  20  per 
cent,  of  women  have  an  abnormally  mobile  and  displaced  right 
kidney,  but  a  very  much  smaller  proportion  exhibit  symptoms 
from  it. 

The  ureter^  in  the  female  is  somewhat  shorter  and  wider  than 
in  the  male.  It  is  accompanied  into  the  pelvic  cavity  by  the  in- 
ternal spermatic  vessels.  In  the  pelvis  the  ureter  comes  into 
relationship  from  above  downward  with  the  following,  struc- 
tures: the  iliac  vessels,  the  uterine  artery,  the  ovary,  the  broad 
and  round  ligaments,  the  pelvic  venous  plexus,  the  cervix  uteri, 
the  vagina,  the  posterior  vesical  wall,  the  rectum.  The  course 
of  the  ureter  is  across  and  in  front  of  the  iliac  vessels,  just 
before  the  internal  iliacs  are  given  off,  downward  along  the 
pelvic  wall  toward  the  tubal  pole  of  the  ovary,  along  the  pos- 
terior border  of  the  ovary  to  the  pelvic  floor.  Running  along 
the  base  of  the  broad  ligament  toward  the  cervix  uteri,  it  is 
directed  downward  and  forward  between  the  anterior  wall  of  the 
vagina  and  the  posterior  wall  of  the  bladder,  for  a  distance  of  i 
to  1.5  centimeters  in  close  relationship  with  the  former. 

Relations  ivith  the  Uterine  Artery. — The  uterine  artery  runs 
with  and  anterior  to  the  ureter  almost  immediately  after  arising 
from  the  hypogastric,  for  4  to  5  centimeters,  then  crosses  in  front 
of  it  at  the  level  of  the  cervix  uteri,  and  pursues  a  course  inward, 
by  a  turn  at  right  angles  toward  the  cervix,  while  the  ureter  con- 
tinues its  course  downward  and  inward. 

Relations  zvith  the  Pelvic  Venous  Plexuses. — In  the  neighbor- 
hood of  the  cervix  the  ureter  runs  between  the  vesicovaginal 
plexus  on  its  outer  side,  and  the  uterovaginal  plexus  on  its  inner 
side. 

Relations  zvith  the  Ovary. — The  free  border  of  the  ovary,   in 

'  The  author  follows  mainly  the  description  of  Waldeyer  in  "  Das  Becken."  A 
most  instructive  and  useful  description  of  the  anatomy  of  the  ureter  is  that  by  Byron 
Robinson  ("  Annals  of  Surgery,"  Dec,  1902).  See  also  Tandler  u.  Halban,  "Topo- 
j^raphie  des  weiblichen  Ureters  mit  besonderer  Berucksichtigung  des  pathologischen 
Zustande  u.  der  gynakologischen  Operationen,"  Wien   u.  Leipzig,  1 901. 

522 


The  Ureter 


523 


the  normal  position  of  the  latter,  rests  directly   upon   the   ureter, 
with  nothing  but  the  peritoneum  between  the  two. 

Relations  with  the  Cervix  Uteri. — The  ureter  passes  the  cer- 
vix in  a  curve  from  above  downward,  from  behind  forward,  and 
from  without  inward.      From  the  point  where  the  uterine  artery 


Fig.  447. — The  anatomical  relations  of  the  ureter  in  the  female:  a,  Aorta;  b, 
median  sacral  artery ;  c,  inferior  vena  cava ;  d,  common  iliac  artery ;  <?,  ovarian 
artery;  f,  colon;  g,  superior  ureteric  artery;  //,  /i,  ureters;  ?',  common  iliac  artery; 
/,  J,  internal  ovarian  venous  plexus ;  /•,  k,  right  and  left  uterosacral  ligaments ;  /, 
hypogastric  artery ;  7>i,  inferior  ureteric  artery ;  71,  uterine  artery ;  0,  0,  ovary ;  p, 
ovarian  ligament;  ^, external  iliac  artery;  r,  epigastric  artery;  5,  vaginal  portion  of 
the  cervix  uteri ;  t,  bladder;  it,  uterus;  z/,  external  iliac  vein  ;  w,  round  ligament ;  x. 
Fallopian  tube  (Tandler  and  Halban). 


crosses,  it  gradually  approaches  the  cervix,  so  that  it  is  nearer  the 
anterior  than  the  posterior  half  of  the  latter.  The  left  ureter  is 
commonly  much  nearer  the  cervix  than  the  right.  The  lower 
the  uterus  descends  or  is  pulled  down,  the  nearer  are  the  ureters 
to  the  cervix. 


524 


Diseases  of  the  Urinary  Tract 


Relations  ivitJi  the  Broad  and  Ronnd  Ligaments. — The  ureter, 
after  entering  the  base  of  the  broad  hgament,  runs  in  the  para- 
metrium, leaving  the  peritoneum  farther  behind  as  it  pursues  its 
course  to  the  bladder.  It  crosses  under  or  behind  the  proximal 
portion  of  the  round  ligament,  from  which  it  is  separated  by  the 
vesicovaginal  venous  plexus. 

Relations  with  the  Vagina. — From  the  level  of  the  lowest  por- 


Fig.  448. — The  relations  of  the  ureter  to  the  uterine  artery  and  the  cervix  uteri  r 
«,  a,  Ureter ;  b,  hypogastric  or  internal  iliac  artery  ;  c,  ovarian  suspensory  ligament ; 
(t,  external  iliac  artery;  ,;•,  uterosacral  ligament;  f,  cervical  canal;  g,  uterine  artery; 
h,  parametrium;  ?',  vaginal  branch  of  uterine  artery;  J,  posterior  wall  of  bladder;  k, 
uterus,  bisected  (Tandler  and  Halban). 

tion  of  the  anterior  lip  of  the  cervix  the  ureters  run  directly 
under  the  anterior  vaginal  wall  in  a  curved  line  inward,  down- 
ward, and  forward  for  i  to  1.5  centimeters  to  their  entrance  into 
the  bladder.  Pawlik  has  called  attention  to  a  transverse  fold  of 
mucous  membrane  on  the  anterior  vaginal  wall  about  2.5  to  3 
centimeters  below  the  external  os  uteri  corresponding  with  the 
base  of  the  vesical  trigonum,  the  lateral  borders  being  represented 


The  Bladder 


525 


Fig.  449. — Relations  of  the  ureteral 
orifices  with  the  internal  meatus  of  the 
urethra  (Viertel). 


by  two  diverging  folds  springing  from  the  upper  end  of  the  an- 
terior column  of  the  vagina.  The  ureters  are  above  this  area  in 
the  vaginal  wall. 

Relations  with  the  Bladder. 
— For  the  space  that  the 
ureters  run  in  relationship 
with  the  vagina  they  are  also 
directly  under  the  posterior 
vesical  wall.  As  they  enter 
the  bladder  they  turn  quite 
sharply  inward.  For  a  short 
distance  the  ureter  runs  within 
the  bladder-wall  (intramural 
portion).  The  greater  the 
distention  of  the  bladder,  the 
wider  the  separation  of  the 
ureters  and  the  greater  their 
elevation  in  the  pelvic  cavity. 

The  following  measurements  of  the  distances  between  the 
ureters  at  different  levels  are  quoted  by  Waldeyer  from  Faytt : 

Separation  of  the  ureters  at  their  origin  from  the  kidneys  .  .  .  6.0-9.0  cm. 
Separation  of  the  ureters  at  the  level  of  the  promontory  .  ,  .  7-0-8.0  cm. 
Separation    of   the    ureters    at    the    level  of  the   fourth    sacral 

vertebra 6.5-9.0  cm. 

Separation  of  the  ureters  at  the  level  of  the  fundus  uteri  .  .  .  6.8-9.5  '^'"• 
Separation  of  the  ureters  at  the  level  of  the  isthmus  uteri  ,  .  ,  5.0-6.5  cm. 
Separation  of  the  ureters  at  the  level  of  the  external  os  uteri  .  4.0-4.5  cm. 
Separation  of  the  ureters  at  their  entrance  in  the  bladder- wall  .  3.0-4.5  cm. 
Separation  of  uretal  orifices  in  the  base  of  the  vesical  trigonum  .  2.5-3.0  cm. 

Separation  of  the  left  ureter  from  the  cervix 0.6-2.0  cm. 

Separation  of  the  right  ureter  from  the  cervix 2.0-3.0  cm. 

The  bladder  of  the  female  is  broader  than  that  of  the  male, 
but  not  so  large  in  its  anteroposterior  diameter.  When  empty 
there  is  a  depression  upon  its  upper  wall  where  the  fundus  uteri 
rests,  and  the  upper  joins  the  posterior  wall  at  quite  a  sharp  angle. 
The  capacity  of  the  female  bladder  is  ordinarily  less  than  that  of 
the  male,  and  its  walls  are  a  third  thinner.  On  this  account  they 
are  more  elastic,  so  that  the  female  bladder  is  capable  of  greater 
distention  under  unusual  internal  pressure  than  is  the  male.  It 
lies  deeper  in  the  pelvis  than  it  does  in  the  male.  The  upper  and 
posterior  walls  are  in  relation  with  the  small  intestines,  the  fundus 
and  corpus  uteri.  The  posterior  wall  below  the  angle  of  its  junc- 
tion with  the  upper  wall  is  in  relation  with  the  vagina  and  the 
anterior  parametrium.  In  front  and  below  is  the  pudendal  venous 
plexus ;  to  either  side  and  below,  the  vesicovaginal  plexuses.  Be- 
hind them  is  the  loose  connective  tissue  connecting  the  bladder 
with  the  vagina  and  cervix.      The  former  can  easily  be  separated 


526  Diseases  of  the  Urinary  Tract 

by  a  blunt  dissection  as  far  down  as  the  urethra,  where  the  vaginal 
wall  adheres  tightly  to  the  urethrovaginal  septum.  In  front 
are  the  s\-mph\-sis  and  fatty  connective  tissue.  Above,  the  peri- 
toneum covers  the  upper  wall  of  the  bladder,  but  not  the  anterior 
or  the  posterior  wall  in  the  empty  condition.  When  distended, 
the  upper  portion  of  the  anterior  wall  is  covered  by  peritoneum, 
but  there  remains  a  space  varying  with  the  degree  of  distention, 
in  which  the  anterior  wall  above  the  symphysis  is  below  and  out- 
side of  the  peritoneal  cavity. 

The  urethra  of  the  female  is  a  cylindrical  canal  3  centimeters 
long,  7  to  8  milHmeters  in  diameter,  but  with  such  elastic  walls 
that  a  gradual  distention  to  2. 5  centimeters  or  more  is  possible 
without  incontinence  of  urine.  There  is  normally  a  spindle- 
shaped  dilatation  of  the  central  portion  of  the  canal.  The  ure- 
thral walls  are  0.5  centimeter  thick.  There  are  the  following 
divisions  of  the  urethra :  The  internal  or  vesical  orifice  ;  the 
intramural,  the  superior  or  free,  the  inferior  or  vaginal  portions, 
and  the  external  or  vestibular  orifice.  According  to  its  relations 
with  surrounding  structures,  the  urethra  is  further  divided  into 
the  supratrigonal,  trigonal,  and  prsetrigonal  portions,  or  from  its 
relation  to  the  levator  ani  muscles  which  run  on  either  side  of 
it,  into  the  superior  portion  above  the  pelvic  diaphragm,  the  pelvic 
portion,  and  the  perineal  or  inferior  portion. 

The  intramural  portion  runs  for  a  very  short  distance  in  the 
bladder-wall.  The  superior  or  free  portion  ends  where  the  urethral 
and  vaginal  walls  firmly  unite  to  form  the  urethrovaginal  sep- 
tum. The  inferior  or  vaginal  portion  ends  at  the  external 
orifice  or  meatus.      The  last  is  much  the  longest  of  the  three. 

The  mucosa  of  the  urethra  is  dark  red  or  purplish  in  color. 
The  cells  vary,  from  below  upward,  from  pavement  epithelium 
in  la}'ers,  to  round  and  cylindrical  cells.  There  are  small  tubular 
glands  in  the  mucosa,  said  to  be  homologues  of  the  prostatic 
glands.  A  group  of  these  glands  empty  by  a  special  efferent 
duct  on  each  side  of  the  external  meatus  (Skene's  ducts). 
There  are  three  layers  of  muscle-fibers  around  the  urethra  : 
an  internal  longitudinal  layer,  next  a  middle,  well-developed 
circular  layer,  and  finally  the  striped  circular  fibers  derived  from 
the  urogenital  trigonum  muscle  (compressor  urethrae).  The 
unstripcd  circular  layer  of  muscle  forms  the  leiosphincter  of 
the  urethra.  The  striped  circular  fibers,  present  along  the 
whole  length  of  the  anterior  urethral  wall,  but  only  directly 
beneath  the  bladder  in  the  free  portion  on  the  posterior  urethral 
wall,  constitute  the  rhabdosphincter  of  the  urethra. 

The  urethra  runs  a  curved  course  downward  and  a  little  for- 
ward, with  its  convexity  directed  backward.      The  internal  orifice 


The  Examination  of  the  Female  Urinary  Tract    527 

is  below  the  middle  of  the  symphysis  and  about  2.5  centimeters 
back  of  it.  In  front  and  to  the  sides  are  the  pudendal  plexus, 
the  urogenital  trigonum,  the  crura  of  the  clitoris,  and  the  bulbs 
of  the  vestibule.  Behind  is  the  vagina,  separated  from  the  free 
portion  by  fibers  of  the  urogenital  trigonum  muscle  and  loose 
connective  tissue,  but  intimately  united  with  the  inferior  or  vaginal 
portion. 

The  arterial  supply  is  from  the  internal  pudic,  the  inferior 
vesical,  and  branches  of  the  cervicovaginal  branch  of  the  uterine 
artery. 

The  veins  empty  into  the  pudendal  and  vesicovaginal  plexuses 
and  are  continuous  with  the  sinuses  of  the  cavernous  bodies  of 
the  clitoris  and  the  bulbs  of  the  vestibule. 

The  spinal  nerve-supply  is  from  the  pudic  nerve. 

The  lymphatics  empty  into  the  hypogastric  and  the  inguinal 
glands. 

The  Examination  of  the  Female  Urinary  Tract. — The  ex- 
amination of  the  urine  is  treated  in  special  works  on  the 
subject.  Investigation  of  the  urine  from  the  female  bladder  is 
governed  by  the  same  rules  that  control  such  examinations  in 
general,  except  that  it  is  always  better  in  the  female  to  examine 
a  catheterized  specimen.  The  collection  of  the  first  part  of  the 
urine  in  a  separate  vessel  is  of  value  in  cases  of  hematuria  and 
of  pyuria  to  determine  whether  the  blood  and  pus  come  from 
the  bladder  or  kidneys.  The  estimation  of  the  amount  of  residual 
urine  by  catheterization  after  spontaneous  urination  is  often 
important  in  cases  of  cystitis  associated  with  cystocele.  In  sus- 
pected neoplasms  of  the  bladder,  the  eye  of  the  catheter,  if  it  is 
employed,  and  the  urinary  sediment  obtained  by  settling  in  a 
conical  glass  or  by  the  centrifuge,  may  contain  fragments  that 
are  suitable  for  microscopic  examination.  In  addition  to  the  ex- 
amination of  the  urine  and  the  use  of  the  catheter,  the  female 
urinary  tract  is  examined  by  the  cystoscope,  the  urethroscope, 
the  fingers,  the  vesical  sound,  and  the  ureteral  bougie  or 
catheter. 

Cystoscopy. — The  inspection  of  the  interior  of  the  bladder  is 
possible  of  late  years  by  means  of  special  instruments — cysto- 
scopes.  Those  at  present  most  generally  used  are  the  Nitze, 
the  cylindrical  specula  of  Pawlik  and  Kelly,  the  Pryor  cysto- 
scope, and  the  Eisner  cystoscope. 

No  cystoscope  is  satisfactory  that  does  not  carry  a  light  at  its 
distal  or  intravesical  end.  Hence  the  cylindrical  specula  of 
Pawlik  and  Kelly,  through  which  the  light  must  be  reflected 
from  the  exterior,  are  awkward  and  inconvenient. 

The  Nitze  cystoscope  has  great  advantages  :  the  illumination 


528 


Diseases  of  the  Urinary  Tract 


is  brilliant ;  it  can  be  used  in  the  ordinary  dorsal  position  ;  it 
magnifies  the  objects  on  which  it  is  brought  to  bear ;  its  field  of 
vision  is  enlarged  by  an  ingenious  system  of  lenses  ;  the  catheter- 
ization of  the  ureters  by  its  aid  is  particularly  easy,  and  the  cali- 
ber of  the  instrument  is  moderate,  so  that  it  can  be  introduced 
without  great  discomfort  to  the  patient.  But  it  has  several  un- 
pleasant disadvantages  :  It  is  necessary  to  distend  the  bladder 
with  water  before  it  is  inserted  ;  the  instrument  can  only  be 
cleansed  by  immersion  in  carbolic  acid  solution  ;  it  is  impossible, 
therefore,  to  make  it  absolutely  aseptic  ;  if  it  is  broken  or  out  of 
order,  it  is  necessary  to  send   it   back  to    Germany  for  repair  ;  i 


Fig.  450. — Nitze's  cystoscope  with  the  electric  wires  attached. 


the  hght  generates  such  heat  that  there  is  danger  of  burning  the 
bladder-walls  or  the  urethra  ;  it  requires  a  very  strong  battery  to 
furnish  enough  power  for  the  light,  ^  and  it  is  impossible  to 
make  applications  to  the  bladder  or  to  touch  anything  through 
it.  One  sees  well,  but  that  is  all.  The  Eisner  cystoscope 
has  replaced  all  other  instruments  in  the  author's  practice. 
It  has  all  the  advantages  of  the  Nitze  instrument  without 
its  disadvantages. 

Cystoscopy  by  the  Nitze  cystoscope  is  conducted  as  follows  : 
The   woman   is   arranged  in  the   ordinary   dorsal   position  ;  the 

^  The  author  has  been  obliged  to  send  his  instrument  to  Berhn,  and  was  then 
compelled  to  pay  full  duty  on  it  again  when  it  entered  America. 

*  This  disadvantage  has  recently  been  obviated  by  an  ingenious  attachment  to  any 
electric  light  fixture,  furnishing  light  for  the  weakest  or  strongest  lamps  of  all  the  endo- 
scopes (made  by  the  Rochester  Electro-surgical  Company). 


Cystoscopy 


529 


external  meatus  is  cleansed  with  pledgets  of  cotton  and  sublimate 
solution  ;  the  cystoscope  is  submerged  in  carbolic  solution,  5 
per  cent.;  the  bladder  is  distended  with  150  c.c.  sterile  water  by 
means  of  a  funnel  and  rubber  catheter  ;  the  cystoscope  is  anointed 
with  sterile  ghxerin  as  an  unguent;  if  the  urethra  is  sensitive,  it 
may  be  cocainized  by  means  of  a  Fritsch's  urethral  tube  attached 
to  a  h}'podermic  syringe.  After  the  introduction  of  the  cysto- 
scope the  attachment  to  the  battery  is  made  and  the  light  is 
turned  on.  The  four  quadrants  of  the  bladder  are  examined  in 
turn,  allowance  being  made  for  the  magnification  of  the  objects 
seen.      Care  must  be  exercised  not  to  touch  the  bladder-walls 


Fig.  451. — Eisner's  ureter  cystoscope:  A,  Catheter;  B,  catheter  carrier  tubes; 
C,  cystoscope;  D,  obturator;  E,  window;  F,  dilating  bulbs;  G,  stop-cock;  H, 
lamp;  I,  irrigator  and  aspirator;  K,  current  attachment;  M,  Eisner  stiletto  probe; 
N,  cocain  applicator. 


with  the  end  of  the  instrument,  which  becomes  very  hot,  and  to 
turn  off  the  light  and  wait  a  moment  before  withdrawing  the  tube 
through  the  urethra.  ^ 

The  Eisner  instrument  is  used  in  the  following  way  :  The 
tip  of  the  cystoscope  is  unscrewed  and  the  lamp  removed  ;  the 
instrument  is  then  boiled  ;  the  patient  is  put  in  the  dorsal  posi- 
tion with  the  buttocks  elevated,  by  tilting  up  a  Trendelenburg 
table  and  by  placing  an  Edebohls  nephrorrhaphy  cushion  under 
her  hips  ;   the  external  meatus   is   cleansed   and   she  is  catheter- 

1  I  have  had  made  cold  lamps  of  equal  brilliancy,  which  are  a  great  improvement 
over  those  that  come  from  Germany. 
34 


530 


Diseases  of  the   Urinary  Tract 


ized  ;  the  urethra  is  cocainized  by  Fritsch's  tube  (4  to  10  per 
cent,  sohition)  ;  if  necessary,  it  is  dilated  by  bougies  ;  a  lamp  is 
inserted  in  the  cystoscope  and  the  top  screwed  tight,  all  manipu- 
lations being  conducted  with  gloved  hands  ;  the  cystoscope,  pro- 
vided with  an  obturator,  is  anointed  with  glycerin  and  inserted  ; 
the  light  is  turned  on  after  the  connection  with  the  battery  is 
made,  recollecting  that  the  small  lamps,  which  do  not  become 
hot,  will  not  stand  a  current  of  more  than  6  volts.  On  removing 
the  obturator  the  bladder  is  distended  with  air.  If  it  does  not 
expand  satisfactorily,  the  instrument  is  provided  with  a  glass 
window  to  be  inserted  in  the  proximal  end  and  with  a  nozzle  and 
stop-cock  through  Avhich  either  air  or  water  can  be  injected  in 
the  bladder  ;  if  the  former  is  used,  the  intake  of  the  bulb  syringe 


Fig.  452. — Aspirator  for  sucking  residual  urine  out  of  the  bladder. 


Fig.  453. — Urethroscope  and  its  obturator. 


should  be  held  near  the  flame  of  an  alcohol  lamp  so  that  the  air 
shall  be  hot  and  consequently  not  irritating  to  the  vesical  mucosa. 
Accumulating  urine  can  be  removed  by  the  suction  apparatus 
(Fig.  452).  This  instrument  not  only  allows  a  good  view  of  all 
portions  of  the  bladder,  but  permits  also  direct  applications  to  the 
mucosa,  the  insertion  of  ureteral  catheters,  the  use  of  forceps,  and 
of  the  wire  ecraseur. 

The  urethra  may  be  examined  by  cylindrical  specula  and  re- 
flected light,  but  the  best  urethroscope  is  a  cylindrical  speculum 
provided  with  a  small  electric  lamp  at  its  distal  extremity. 
Guarded  by  its  obturator,  it  is  inserted  past  the  sphincter  of  the 
bladder.  The  obturator  is  withdrawn,  the  light  is  turned  on  by 
the  rheostat  of  the  battery  to  which  the  wires  are  attached,  and. 


The  Urethra 


531 


the  instrument  is  slowly  withdrawn,  so  that  the  vesical  sphincter 
and  successive  folds  of  the  mucosa  come  plainly  into  view.  The 
bladder  must  be  empty  before  the  urethroscope  is  inserted. 

The  battery  for  the  cystoscope  and   urethroscope   may  be  a 
small,    light,   dry-cell   battery  with   a   rheostat,  if  one   uses   the 


Fig   454. — Light  carrier  for  urethroscope. 


Fig.  455. — Attachment  to  electric  light  fixture  for  the  light  of  any  of  the  endoscopes. 

American  instruments.  The  Nitze  cystoscope  requires  a  much 
more  powerful  and  heavier  battery.  There  has  been  recently  in- 
troduced a  very  convenient  attachment  to  the  electric  light 
fixtures  of  any  house  or  office  that  gives  the  necessary  light  for 
all  kinds  of  endoscopes,  obviating  the  necessity  of  transporting  a 


532  Diseases  of  the   Urinary  Tract 

battery  and  avoiding  the  awkward  possibility  of  a  failure  of 
current  in  the  midst  of  an  examination. 

The  ureters  are  examined  by  the  cystoscope,  the  ureteral 
sound  or  catheter,  and  by  palpation. 

By  the  cystoscope  the  urethral  orifices  are  inspected.  They 
lie  at  either  extremity  of  the  inter-ureteric  ligament,  at  the  angles 
of  the  base  of  the  trigonum.  Their  separation  from  one  another 
varies  from  i  3  to  40  millimeters,  and  the  distance  of  the  inter- 
ureteric  ligament  from  the  vesical  sphincter  varies  from  8  to  35 
millimeters.  One  ureteral  orifice  is  first  located  by  deflecting  the 
cystoscope  toward  the  corresponding  side  ;  the  other  is  then  found 
by  moving  the  end  of  the  cystoscope  along  the  inter-ureteric  liga- 
ment until  the  other  comes  in  view.  The  orifices  are  usually  at 
the  apex  of  a  little  nipple  and  are  circular  in  outline.  They  may 
be  slit-like  in  shape,  or  simple  depressions  without  a  nipple-like 
projection.      Blood-vessels  commonly  radiate  from   them  in  the 


Fig.  456. — Different  forms  of  ureteral  orifices  (Viertel). 

bladder- wall  and  the  urine  is  projected  from  them  in  intermittent 
spurts  showing  the  peristalsis  of  the  ureters  and  the  probability 
that  they  are  provided  with  a  sphincter  that  prevents  regurgitation 
of  urine  from  the  bladder. 

If  it  is  desired  to  collect  the  urine  from  the  ureters  sepa- 
rately, a  ureteral  catheter  may  be  readily  inserted  by  either  the 
Nitze  cystoscope  or  the  Eisner  instrument.  The  latter  is  pro- 
vided with  two  separate  little  tubes  each  furnished  with  a  flexible 
catheter  so  that  both  ureters  may  be  catheterized,  one  after 
the  other,  without  withdrawing  the  cystoscope.  It  is  usually 
more  convenient,  but  not  necessary,  to  keep  a  stylet  in  the  cathe- 
ter until  its  point  is  well  engaged  in  the  ureteral  orifice,  when  it 
is  withdrawn  and  the  catheter  is  pushed  in  as  far  as  is  desired, 
even  to  the  pelvis  of  the  kidney.  The  catheters  should  be  of 
different  colors, — red  and  black, — and  a  note  should  be  taken  of 
which  is  in  the  right,  which  is  in  the  left  ureter.  If  they  are 
pushed  in  far  enough  there  is   little  danger  of  their  slipping  out. 


The  Ureters 


533 


Thev  can  remain  for  as  many  hours  as  is  desired,  until  a  sufficient 
quantity  of  urine  is  collected  in  separate  vessels  from  each  kidney 
or  until  ample  time  is  allowed  to  demonstrate  the  absent  or 
deficient  function  of  one  kidney.  Meanwhile  the  woman  is  re- 
moved from  the  table  on  which  the  cystoscopy  has  been  prac- 
tised and  rests  comfortably  in  bed. 

If  it  is  desired  to  sound  and  not  to  catheterize  the  ureters,  the 
procedure   may  be  the  same,  or   an   inflexible  metal   instrument 


Fig.  457. — Ureteral  catheters  in  the  ureters  (Viertel). 


Fig.  458. — Harris'  instrument  for  collecting  the  urine  separately  from  the  two 
kidneys:  a.  Catheters  turned  down ;  b,  sheath  with  scale;  c,  vaginal  rod;  d,  d,  vials 
for  collecting  urine ;  e,  exhaust  pump. 


may  be  used.  Kelly  has  designed  a  wax-tipped  sound  to 
test  for  calculi.  The  x-ray,  however,  is  more  rehable  for  this 
purpose.  Metal  or  wax-tipped  sounds  must  be  inserted  through 
the  main  lumen  of  the  cystoscope,  which  is  more  difficult  than 
through  the  special  tube  in  the  wall  of  the  cystoscope  provided 
for  the  purpose.  They  can  only  be  employed  through  the  open 
cylindrical   instrument.      No  direct  manipulation  or  instrumenta- 


534 


Diseases  of  the  Urinary  Tract 


tion  is  possible  through  the  Nitze  cystoscope,  except  the  use  of 
the  wire  snare  through  the  "operating"  cystoscope. 

Two  instruments  have  been  designed  to  collect  the  urine  sep- 
arately from  the  ureters  without  catheterization.  The  Harris 
instrument  makes  a  watershed  of  the  vesical  wall  between  the 
two  ureteral  orifices.  It  is  reliable  and  efficient  for  its  purpose, 
no  doubt,  but  is  painful  to  the  patient  and  scarcely  inspires  the 
physician  with  the  same  certainty  that  he  is  obtaining  the  result 
desired  as  does  the  catheterization  of  the  ureters.  The  author  has 
used  it  if  catheterization  of  the  ureters  has  been  unsatisfactory  or 
is  impracticable. 

The  other  instrument,  designed  by  Cathelin,  is  more  use- 
ful in  the  male  bladder.  It  is  supposed  to  establish  a  water-tight 
barrier  between  the  two  ureteral  orifices  by  a  rubber  diaphragm. 


Fig.  459. — Cathelin' s  urinary  segregator. 


Palpation  of  the  ureters  is  only  possible  if  they  are  patho- 
logically thickened  and  if  they  are  not  surrounded  by  cellulitic 
exudate.  In  a  favorable  case  they  may  be  felt  in  their  course 
from  the  bladder  through  the  vesicovaginal  septum  and  the  para- 
metrium by  a  vaginal  examination.  The  fingers  of  the  left  hand 
palpate  the  left  ureter  while  pressure  is  made  from  above  through 
the  abdominal  wall.  The  right  hand  is  used  internally  to  pal- 
pate the  right  ureter.  The  index  finger  or  the  index  and  middle 
fingers  are  swept  outward  from  the  middle  line  over  the  upper 
anterior  vaginal  wall  until  the  cord-like  ureter  is  felt.  The 
Fallopian  tube  or  the  round  ligament  might  be  mistaken  for  it,  if 
one  is  not  careful  to  trace  the  course  of  the  structure  felt. 


Diseases  of  the  Bladder  535 

The  kidney  is  examined  by  bimanual  palpation.  The  most 
convenient  way  is  to  sit  the  patient  bolt  upright,  with  the  back 
supported,  the  feet  resting  upon  a  support  that  keeps  the  legs 
and  thighs  well  flexed,  the  arms  hanging  limp  by  her  side,  while 
she  breathes  deeply  through  her  mouth.  One  outspread  hand 
of  the  examiner  is  placed  over  the  lumbar  region,  the  fingers  of 
the  other  are  inserted  under  the  floating  ribs  in  front.  The  mobil- 
ity, size,  and  position  of  the  kidney  may  be  thus  appreciated  in  a 
favorable  case — that  is,  if  the  patient  is  thin,  has  relaxed  abdomi- 
nal walls,  and  particularly  if  the  kidney  occupies  a  lower  position 
than  normal.  Other  methods  of  palpating  the  kidney  are  prac- 
tised as  follows  :  (i)  The  patient  is  placed  in  the  dorsal  position, 
with  the  thighs  flexed  and  abducted  and  with  the  legs  flexed  on 
the  thighs;  (2)  the  patient  stands  with  the  body  bent  for- 
ward, supported  by  resting  her  hands  on  the  back  of  a  chair  ; 
or  (3)  she  assumes  the  knee-elbow  position.  In  any  of  these 
positions,  the  palpation  is  conducted  by  the  physician  as  already 
described,  the  lower  pole  of  the  kidney  at  least  being  caught  and 
balanced  between  the  hands.  If  it  is  compressed  between  the 
fingers  of  the  outspread  hands,  it  may  usually  be  displaced 
upward  under  the  ribs.  If  the  kidney  is  the  seat  of  a 
tumor,  the  ordinary  dullness  on  percussion  in  the  loins  extends 
outward  and  forward.  The  course  of  the  colon  over  the  tumor  may 
be  mapped  out.     There  is  no  resonance  behind  a  renal  tumor. 

Congenital  malformations  of  the  bladder  are  in  the  main  the 
same  in  both  sexes.  Exstrophy,  diverticula,  and  vertical  septa 
are  more  common  in  males  than  in  females.  There  may  be  ab- 
sence of  the  bladder  with  insertion  of  the  ureters  in  the  urethra. 
Hypospadias  and  epispadias  have  the  peculiarities  in  the  female 
that  in  the  former  there  is  often  an  associated  ill  development  of  the 
vagina  and  coitus  may  be  practised  per  iircthram  into  the  bladder 
without  developing  incontinence  ;  in  the  latter  there  is  an  opening 
into  the  bladder  through  the  lower  anterior  abdominal  wall  above 
the  symphysis. 

Displacements  of  the  Bladder. — In  addition  to  the  common 
displacement  of  a  cystocele  already  described,  there  may  be  a 
hernia  of  the  bladder  through  the  inguinal  or  crural  canal.  There 
is  usually  a  sacculated  condition  or  a  diverticulum  in  such  cases. 

Diseases  of  the  Bladder. — Cystitis  is  an  inflammation  of  the 
vesical  mucosa  caused  by  microbic  infection  or  by  chemical  irri- 
tation. The  vast  majority  of  cases  are  due  to  infection.  The 
micro-organisms  responsible  for  the  inflammation  are  bacilli  or 
cocci.  Among  the  former  are  the  tubercle  bacillus,  the  bacte- 
rium coli  commune,  the  urobacillus  liquefaciens  septicus,  the 
coccobacillus,  and  the  typhoid  bacillus  ;  among  the  latter,  gono- 


536  Diseases  of  the  Urinary  Tract 

cocci,  streptococci,  and  staphylococci.  The  micro-organisms  are 
usually  introduced  into  the  bladder  by  a  catheter,  but  they  can 
wander  in  from  the  urethra  ;  they  may  come  from  the  blood,  as 
in  typhoid  and  the  other  infectious  fevers  ;  they  may  be  carried 
into  the  bladder  through  a  perforation  in  its  wall  by  which  a 
pelvic  abscess  may  be  evacuated  ;  they  may  penetrate  the  bladder- 
wall,  as  in  a  case  of  septic  peritonitis  or  paravesical  abscess  before 
rupture ;  they  may  come  direct  from  the  bowel  through  an 
enterovesical  fistula ;  and  they  may  descend  from  the  kidneys 
or  ureters.  The  vesical  mucous  membrane  in  its  normal  condi- 
tion is  resistant  against  infection.  Pus  may  flow  through  the 
bladder  from  a  pelvic  abscess  or  from  the  kidneys  without 
exciting  cystitis.  Predisposition  is  usually  necessary  for  the 
outbreak  of  a  cystitis,  in  a  lowered  vitality  of  the  bladder  epi- 
thelium, congestion  or  traumatism  of  the  mucosa.  The  com- 
monest cause  of  a  lowered  resisting  power  is  overdistention  of 
the  bladder.  Particularly  virulent  micro-organisms,  however,  are 
capable  of  exciting  an  inflammation  in  a  perfectly  healthy  and 
normal  vesical  mucosa.  It  is  said  that  two  hours  suffice  for  the 
ammoniacal  decomposition  of  the  urine  and  the  inception  of  a 
septic  cystitis  (Roosing). 

Chemical  irritation  as  a  cause  of  cystitis  may  follow  the  ad- 
ministration of  drugs.  Cantharides  has  this  power  preeminently. 
It  is  also  the  result  of  injecting  strong  solutions  into  the  bladder. 
It  is  a  disputed  point  whether  the  ammoniacal  decomposition  of 
urine  by  the  micrococcus  ureae  and  other  organisms  is  a  cause  or 
the  effect  of  cystitis.  The  weight  of  expert  opinion  leans  to  the 
latter  view. 

TJie  Varieties  of  Cystitis. — The  commonest  kind  of  cystitis  is 
an  acute  catarrhal  inflammation  affecting  most  severely  the 
base  of  the  bladder,  but  extending  at  least  as  a  marked  injection 
of  the  vessels,  to  the  rest  of  the  mucosa.  Under  appropriate  treat- 
ment this  form  of  cystitis  quickly  subsides  and  disappears  without 
serious  consequences.  If  neglected  or  inappropriately  treated, 
it  results  in  a  chronic  inflammation  of  the  trigonum  and  neighbor- 
ing mucosa  (see  Plate),  with  distressing  symptoms,  often  obsti- 
nately resisting  treatment.  Another  frequent  form  is  a  hyperemia 
rather  than  an  actual  inflammation  from  the  congestion  of  men- 
struation, pregnancy,  neighboring  pelvic  and  abdominal  tumors, 
masturbation,  sexual  or  alcoholic  excess,  and  the  use  of  some 
drugs,  as  cantharides.  The  presence  of  a  stone  or  a  neoplasm 
in  the  bladder  may  produce  either  a  hyperemia  or  an  intense 
cystitis. 

Membranous  cystitis  is  rare,  occurring  in  the  gravest  forms  of 
vesical  infection  in  the   puerperium  or  in  consequence  of  the  ex- 


PLATE  13. 


A,   Cystitis  of  the  trigonum;    B,  ulcerative  cystitis,    with  a  history  of   gonorrheal 

infection. 


Cystitis  537 

tremc  distention  of  the  bladder  with  an  incarcerated  retroflexed 
uterus  or  with  a  myoma  impacted  in  the  pelvis.  The  vesical 
mucosa  is  thickened,  gangrenous,  and  exfoliated.  Masses  of  foul 
membrane  are  expelled  with  tlie  urine,  which  has  a  horribly  fetid 
odor,  or  block  up  the  neck  of  the  bladder  and  obstruct  the  flow 
of  urine.  Suppuration  occurs  under  the  exfoliated  membrane  and 
pus  may  be  evacuated  in  large  quantities  by  pushing  a  catheter 
through  the  soft,  necrotic  mucosa. 

Tuberculous  cystitis  is  usually  seen  in  young  women  or  girls 
and  is  almost  always  the  consequence  of  a  tuberculous  nephritis. 
There  first  appear  little  grayish  nodules  in  the  trigonum  and 
neighborhood  of  the  ureteral  orifices,  surrounded  by  an  area 
of  reddened  membrane  ;  caseation  and  ulceration  of  the  tuber- 
cles rapidly  follow,  with  coalescence  of  the  ulcers,  until,  in  ex- 
treme cases,  the  whole  interior  of  the  bladder  is  an  ulcerated 
surface,  the  color  of  raw  beef. 

Gonorrlical  cystitis  predisposes  to  tuberculosis.  The  urine,  in 
spite  of  the  large  quantity  of  pus  in  it,  remains  acid.  Ulcerative 
cystitis  is  not  always  tuberculous.  Small  ulcers  develop  in  the 
gonorrheal  form  (see  Plate),  may  be  the  result  of  pressure-necroses 
in  labor,  and  may  be  due  to  thromboses  or  emboli  in  the  vessels 
of  the  bladder-wall.  In  exceptional  cases  the  ulcer  perforates  the 
bladder-wall. 

Syuiptonis  and  Diagnosis. — The  three  distinctive  symptoms 
of  cystitis  are  vesical  tenesmus,  pain,  and  mucopus  in  the  urine. 
In  the  acute  form  there  is  fever,  usually  moderate  in  degree, 
sometimes  high.  Hematuria  is  not  symptomatic  of  cystitis  in 
the  female,  as  it  often  is  in  the  male.  In  tuberculous  cystitis 
there  may  be  intense  vesical  pain  and  tenesmus  and  evidence  of 
tuberculous  processes  elsewhere.  There  is  always  loss  of  weight. 
Tubercle  bacilli  in  the  urine  are  a  positive  sign,  but  they  are  not 
easily  or  always  found.  ^  Membranous  cystitis  is  recognized  by 
the  mechanical  obstacle  to  the  evacuation  of  the  bladder,  by  the 
foul  odor,  by  the  passage  of  necrotic  mucosa,  and  by  the  feel  of  the 
desquamated  membrane  when  the  catheter  is  introduced  ;  also  by 
the  evacuation   of  pus  collected  behind  the  membrane.      There 

1  The  examination  for  tubercle  bacilli  in  the  urine  is  conducted  as  follows  :  The 
total  amount  of  urine  passed  in  twenty-four  hours  is  collected  and  allowed  to  sediment 
for  twenty-four  hours.  The  supernatant  urine  is  decanted  off  and  the  sediment  is  centrif- 
ugated  in  successive  portions,  each  time  pouring  off  the  clear  urine,  until  the  tube  of 
the  centrifuge  is  half  full  of  the  purulent  sediment.  A  portion  of  this  is  then  spread 
thinly  on  glass  slides,  at  least  four  of  which  should  be  prepared.  A  slide  is  preferable 
to  a  cover-glass,  as  it  gives  a  wider  field  for  examination.  The  slides  are  then  fixed 
and  stained  in  the  ordinary  way  ;  by  hot  carbol-fuchsin  for  five  minutes,  decolorized  by 
'5  per  cent,  sulphuric  acid  till  no  red  tinge  remains  on  the  slide  (usually  thirty  to  sixty 
seconds),  and  counterstained  by  an  aqueous  solution  of  raethylene-blue.  This  method 
gives  a  clearer  specimen  than  can  be  obtained  by  the  use  of  Gabbett's  stain. 


538  Diseases  of  the  Urinary  Tract 

may  be  pneumaturia  and  a  fecal  odor  to  the  urine  if  there  is  a 
communication  with  the  bowel  ;  but  pneumaturia  is  possible 
without  a  urinary-fecal  fistula.  If  the  latter  exists,  vegetable 
matter  and  striped  muscle-fiber  may  be  seen  in  the  urine  in  a 
microscopical  examination.  The  best  and  surest  means  of  diag- 
nosticating cystitis  in  all  its  forms  is  cystoscopy.  Tubercles,  ulcers, 
fistulas,  foreign  bodies,  neoplasms,  and  calculi  can  be  seen.  The 
degree  and  extent  of  the  inflammation  of  the  mucous  membrane 
are  also  plainly  visible. 

Treatment. — For  an  acute  cystitis  the  treatment  should  be 
rest  in  bed,  liquid  diet,  large  quantities  of  water  by  the  mouth, 
the  administration  of  urotropin  and  salol,  each  5  grains,  alternat- 
ing every  three  hours,  and  an  irrigation  of  the  bladder  twice  a 
day  with  boracic  acid  solution,  grs.  xv-f§j,  through  a  two-way 
catheter  or  by  an  ordinary  soft-rubber  catheter  attached  to  a 
funnel  ;  4  to  8  ounces  of  the  solution  should  be  poured  in  at  a 
time,  allowed  to  remain  for  a  minute  or  two,  and  then  allowed  to 
flow  out.  If  the  two-way  catheter  is  used,  the  outlet  is  stopped 
by  the  thumb  until  the  desired  quantity  is  injected  ;  if  the  funnel 
and  catheter  are  employed,  depressing  and  inverting  the  former 
drains  off  the  fluid  in  the  bladder.  The  injection  should  be  re- 
peated at  least  half  a  dozen  times  at  a  sitting.  If  the  fluid  is 
simply  allowed  to  flow  through  a  two-way  catheter,  only  the 
lower  part  of  the  bladder  is  washed  unless  the  tip  of  the  catheter 
is  pushed  in  until  it  impinges  against  the  vertex  of  the  bladder ; 
even  then  the  lateral  walls  are  not  irrigated.  If  the  cystitis  is 
gonorrheal  in  origin,  4  to  6  ounces  of  a  2  to  5  per  cent,  argyrol 
solution  should  be  injected  after  the  boracic  acid  irrigation  and 
should  be  allowed  to  remain  until  it  is  spontaneously  evacuated. 

In  ulcerative  cystitis  the  ulcers  should  be  treated  through  a 
cylindrical  cystoscope  by  applications  of  the  strongest  possible 
solutions  of  nitrate  of  silver  or  by  fusing  the  solid  salt  on  the  end 
of  a  probe.  A  few  applications  usually  sufiflce.  If  they  are  fol- 
lowed by  bleeding  from  the  ulcerated  surfaces,  Shober  suggests 
applying  powdered  suprarenal  extract  or  adrenalin  solution.  If 
the  ulceration  is  too  extensive  for  such  strong  applications,  the 
treatment  may  be  like  that  of  gonorrheal  cystitis.  Persistent 
irrigation  alone  will  sometimes  cure  the  most  unpromising  cases.  ^ 
Drainage  by  a  vesicovaginal  fistula  is  sometimes  necessaiy.  A 
sound  is  inserted  through  the  urethra  past  the  neck  of  the 
bladder.  Its  point,  held  firmly  in  the  middle  line,  is  depressed 
to  make  the  vesicovaginal  septum  prominent ;  a  vertical  opening 

^  I  have  seen  a  tuberculous  ulceration  of  the  bladder  occupying  its  whole  inner 
surface  cured  in  this  way.  Some  months  after  the  institution  of  the  treatment  the 
vesical  mucosa  was  perfectly  white  and  entire,  but  much  thickened  and  wrinkled. 


Contraction   of  the   Bladder  539 

is  made  through  the  septum  upon  the  point  of  the  sound  with 
knife  or  scissors  ;  the  vesical  is  united  to  the  vaginal  mucosa 
with  interrupted  catgut  sutures.  After  the  cystitis  is  cured,  the 
opening  is  closed  by  an  operation  for  the  vesicovaginal  fistula. 
Urethral  drainage  may  suffice,  and,  if  it  does,  is  to  be  preferred 
to  vesicov^aginal  drainage.  A  Skene's  catheter  is  inserted  in  the 
urethra  ;  a  rubber  tube  is  attached  to  it  and  led  into  a  urinal.  Reg- 
ular irrigation  is  required  to  keep  the  catheter  from  being  clogged 
with  urinary  salts.  A  simpler  and  often  a  better  plan  is  to  fill 
the  bladder  with  water ;  to  insert  a  piece  of  rubber  tubing  in 
the  urethra  until  the  water  in  the  bladder  escapes, — that  is,  just 
past  the  sphincter  at  the  neck  of  the  bladder, — and  then  to  fasten 
the  tube  by  a  few  fine  silk  stitches  to  the  mucous  membrane  of  the 
external  meatus.  The  tube  must  be  long  enough  to  be  led  into  a 
urinal.  The  external  meatus  should  be  cocainized  before  insert- 
ing the  tube  and  the  stitches.  Membranous  cystitis  usually 
requires  vesicovaginal  drainage,  frequently  repeated  irrigation  with 
boric  acid  solution,  the  removal  of  necrotic  membrane  with 
forceps  through  the  fistula  or  the  urethra,  and  the  evacuation 
of  pus  collected  behind  the  partially  exfoliated  membrane.  It 
may  be  necessary  to  direct  the  treatment  rather  to  the  cause  of 
the  inflammation  than  to  the  cystitis  itself  Calculi  and  neoplasms 
must  be  removed.  If  there  is  a  constantly  recurring  infection 
from  the  kidneys,  a  pelvic  abscess,  or  the  bowel,  the  pyelitis,  the 
pelvic  abscess,  or  the  fecal  fistula  must  be  cured  before  the  cysti- 
tis can  be  expected  to  get  well.  Nephrotomy,  drainage  of 
the  pelvis  of  the  kidney,  or  nephrectomy  may  be  required.  It 
may  be  necessary  to  drain  a  pelvic  abscess  through  an  incision 
into  the  parametrium  above  Poupart's  ligament,  or  in  the  same 
way  to  establish  a  vent  for  the  fecal  fistula,  whereupon  the  open- 
ing in  the  bladder  commonly  closes  quickly. 

Contraction  of  the  bladder,  with  a  consequent  diminution  of 
capacity  and  distressing  frequency  of  urination,  is  often  seen  in 
women,  usually  originating  in  a  nervous  habit  of  frequent  urina- 
tion, but  sometimes  the  result  of  cystitis,  of  inflammatory  adhesions 
around  the  bladder,  and  of  an  anterior  fixation  of  the  uterus.  The 
diagnosis  is  made  by  injection  of  measured  quantities  of  water  and 
by  cystoscopy.  The  capacity  of  the  bladder  may  be  reduced  to 
an  ounce  or  two,  as  is  demonstrated  if  water  is  allowed  to  flow 
through  a  rubber  tube  attached  to  a  funnel  at  a  height  of  a  foot 
above  the  bladder.  Cystoscopy  shows  a  wrinkled  and  corrugated 
mucosa.  The  treatment  is  daily  injections  of  increasing  quantities 
of  water,  beginning  with  a  small  amount  and  very  gradually  in- 
creasing it  so  as  to  avoid  unnecessarily  hurting  and  discouraging 
the  patient.      She  can  co-operate  with  the  physician  by  resolutely 


540  Diseases  of  the  Urinary  Tract 

increasing  the  intervals  between  urinations  from  day  to  day,  if 
only  by  five  minutes. 

Neoplasms  of  the  Female  Bladder.— Neoplasms  of  the  bladder 
are  most  commonly  papilia/iatoiis  polyps,  although,  Uke  all  tumors 
of  the  bladder,  they  are  rare.  The  tumor  is  usually  pedunculated, 
grows  very  slowly,  and  occasionally  reaches  a  large  size.  There 
is  profuse  hemorrhage,  which  is  the  chief  clinical  symptom,  a 
tendency  to  recurrence  and  to  carcinomatous  degeneration.  The 
growth  is  not  essentially  malignant,  but  can  scarcely  be  called 
benign. 

Carcinoma  of  ilie  bladder  is  usually  an  extension  of  carcinoma 
of  the  cervix   uteri.      It   can,    however,    occur  primarily   in   the 
vesical  Avail  as  a  submucous  thickening  followed  by  surrounding 
nodes,  and  eventually  ulceration.      The  symptoms  are  at  first  ves- 
ical tenesmus  and  pyuria ;  later  hematuria, 
foul-smelling  urine,  infection  of  the  ureters 
and  of  the  pelves  of  the  kidneys. 

Mucous  polyps  occur  mainly  in  chil- 
dren and  young  girls,  grow  rapidly,  reach 
a  large  size,  and  may  protrude  from  the 
external  meatus  of  the  urethra. 

Adenoma,  myoma,  dermoid,  and  sar- 
coma 1    of  the  bladder   have   been    des- 
cribed.   The  rupture  of  a  vesical  dermoid 
Fig.  460. -Papillomatous     "ito  the  bladder  and   discharge    of  hair 
polyp  of  the  bladder  (Vier-     (trichiasis   vesicse)   suggcst  the    opening 
t^O-  of  an  ovarian  dermoid  (ovulogenous  cyst) 

into  the  bladder.  Hysterical  women 
have  been  known  to  put  hair  into  their  urine  to  excite  sympathy 
and  interest. 

The  most  distinctive  symptom  of  neoplasms  in  the  bladder  is 
hematuria.  Pain  may  be  absent.  Tenesmus,  pyuria,  and  sudden 
interruption  of  the  stream  of  urine  may  be  observed. 

Palpation  of  the  bladder  in  a  bimanual  examination  may 
reveal  a  tumor  in  it,  but  the  growth  may  be  so  soft  that  it  is  im- 
perceptible. A  catheter  may  remove  a  small  piece  of  the  growth 
in  its  fenestra.  Palpation  of  the  bladder  by  the  insertion  of  the 
little  finger  through  the  urethra  or  by  the  insertion  of  a  finger 
through  an  exploratory  incision  in  the  vesicovaginal  septum  is 
permissible,  but  the  diagnosis  is  best  made  by  cystoscopy. 

The  treatment  is  the  removal  of  the  growth  by  a  wire  snare 

1  I  had  the  opportunity  of  seeing  an  interesting  case  of  the  kind  in  the  service  of 
my  colleague,  Dr.  John  B.  Shober.  The  tumor  projected  into  the  bladder,  pene- 
trated its  wall,  and  was  attached  to  the  periosteum  of  the  horizontal  ramus  of  the 
pubis. 


Urinary  Fistiilae  541 

through  the  urethra,  by  an  incision  through  the  vcsicov^aginal 
septum,  or  by  a  suprapubic  cystotom\'.  In  a  vaginal  cystotomy 
the  knee-chest  posture  is  an  advantage.  The  best  method  is  the 
suprapubic  cystotomy  in  the  Trendelenburg  posture.  A  transverse 
incision  is  made  just  above  the  symphysis,  the  bladder  is  pushed 
up  into  the  wound  by  a  sound  in  it ;  a  transverse  incision  is  made 
in  the  vertex,  and  its  edges  seized  with  hemostats.  The  tumor 
is  removed  by  scissors,  the  knife,  a  curet,  the  electrocautery 
knife,  or  a  Paquelin  cautery,  the  pedicle,  if  possible,  being  ligated. 
The  insertion  of  the  urethroscope  lamp  on  its  slender  stem  is 
often  a  valuable  aid  in  the  intravesical  manipulations.  If  the 
hemorrhage  is  uncontrollable  the  bladder  and  vagina  are  both 
packed  and  additional  pressure  is  made  by  a  firm  abdominal 
binder,  a  fenestrated  rubber  tube  being  placed  in  the  bladder  with 
one  end  projecting  from  the  urethra  and  the  other  through  the 
abdominal  wound.  Through  this  tube  the  bladder  may  be  irri- 
gated with  boracic  acid  or  astringent  solutions.  The  packing  is 
removed  in  twenty-four  or  forty-eight  hours.  The  tube  remains 
in  place  for  some  time,  until  the  abdominal  wound  cicatrizes. 
The  extirpation  of  the  bladder  wholly  or  in  part  for  malignant 
disease  and  the  implantation  of  the  ureters  in  the  vagina,  the  ure- 
thra, the  external  skin,  or  in  the  rectum  has  been  proposed  and 
carried  out,  but  the  results  so  far  have  not  been  satisfactory. 
Ureteritis  and  nephritis  probably  follow  even  if  the  immediate 
results  of  the  operation  are  good.  Implantation  in  the  vagina  is 
preferable  to  implantation  in  the  rectum,  which  is  always  followed 
by  an  ascending  infection  of  the  ureters. 

Vesical  calculus  in  the  female  deserves  no  special  consideration 
except  for  its  extreme  rarity  ^  and  the  possibility  of  an  easy  re- 
moval through  a  vesicovaginal  incision.  The  symptoms  are  the 
same  in  both  sexes  and  the  diagnosis  is  made  in  the  same  way — 
by  cystoscopy  and  by  a  metal  sound.  A  bimanual  vaginal- 
abdominal  examination  may  be  practicable  in  the  female  as  a 
means  of  diagnosis,  but  cystoscopy,  so  easily  carried  out  in 
women,  should  always  precede  an  operation  for  stone  in  the 
bladder. 

Urinary  fistulas  are  usually  the  result  of  pressure  necroses 
following  labor.  They  are  becoming  very  rare  in  all  civilized 
countries  in  which  women  receive  proper  attention  in  partu- 
rition. It  is  a  question  whether  more  are  not  encountered 
to-day  from  injuries  in  gynecological  operations,  especially  in 
hysterectomy  for  cancer  of  the  cervix.  ^      A  neglected  pessary 

1  According  to  Ultzmann,  vesical  calculus  is  200  times  more  frequent  in  men 
than  in  women. 

2  In  the  beginning  of  my  practice  I  saw  several  vesicovaginal  fistulte  a  year  fol- 
lowing labor.      Now  I  do  not  see  one  a  year. 


542 


Diseases  of  the  Urinary  Tract 


sometimes  ulcerates  through  the  vesicovaginal  septum.  Other 
causes  are  fractured  pelvis,  injury  of  the  vagina  in  attempts  at 
criminal  abortion,  ulcerations  through  the  vaginal  wall  of  a 
vesical  calculus  or  of  a  foreign  body  inserted  in  the  bladder,  in- 
jury to  the  bladder-wall  in  anterior  vaginal  fixation  of  the  uterus, 
anterior  colporrhaphy,  symphyseotomy  or  myomectomy,  and  in 
obstetrical  operations  such  as  the  use  of  blunt  hooks,  attempts  at 
version,  clumsy  insertion  of  the  forceps,  forcible  extraction  of  the 
head  past  a  prolapsed  cystocele,  and  craniotomy. 

The  fistulae  following  pressure-necroses  in  a  prolonged  labor 
are  easily  avoidable  by  the  proper  and  timely  use  of  the  forceps 


Fig.  461. — Fistulae  of  the  genital  organs:  a,  Vesicouterine  fistula;  b,  vesico- 
cervical iistula ;  c,  vesicovaginal  fistula ;  d,  urethrovaginal  fistula ;  e,  rectovaginal 
fistula;  f,  perineovaginal  fistula  (Beigel). 


or  by  the  other  obstetrical  operations  that  may  be  indicated  in 
an  insuperably  obstructed  labor.  In  more  than  10,000  women 
delivered  in  the  hospital  services  with  which  the  author  is  con- 
nected there  has  not  been  a  single  urinary  fistula  following  labor. 

Urinary  fistulae  may  be  classified  as  follows :  vesicovaginal 
fistulse ;  vesico vestibular  fistulae;  uterovesicovaginal  fistulae:  {a) 
superficial,  through  the  anterior  lip  of  the  cervix,  which  forms  the 
upper  wall  of  the  sinus  ;  {p)  deep,  through  the  uterine  wall,  the 
anterior  lip  of  the  cervix  having  sloughed  off;  uterovesical  fis- 
tulae; urethral  fistulae;  enterovesical  fistulae;  colovesical  fistulae; 
ureterovaginal  and  uterine  fistulse. 

The  opening  into  the  bladder  varies  in  size  and  shape  from  a. 


Urinary  Fistulae 


54: 


pin-point  orifice  to  a  defect  of  the  whole  base  of  the  bladder,  and 
from  a  round  hole,  regular  as  if  punched  out  with  an  instrument, 
to  a  jagged  opening  usually  running  across  the  vagina,  with  off- 
shoots running  up  the  anterior  sulci,  or  in  the  median  line.  The 
vesical  mucosa  of  the  vertex  may  prolapse  through  a  large  open- 


Fig.  462. — Vesicovaginal  fistula. 


ing.  Irritated  by  discharges  and  attrition,  it  becomes  hyper- 
trophied  and  inflamed. 

The  urethra  is  often  wanting  in  its  upper  part  and  its  canal 
may  be  obliterated. 

Uterovesical  fistulae  are  usually  situated  in  the  anterior  lip  of 
the  cervix,  near  the  internal  os.  They  are  usually  on  the  left 
side  of  the  median  line  and  are  small  in  caliber. 

Enterovesical  fistulae  are  exceedingly  rare.  Fritsch  ^  in  his 
enormous  experience  has  seen  but  a  single  case. 

Colovesical  fistulae  are  more  common.      They  are  usually  the 

^  Fritsch  operated  on  200  urinary  fistulae  in  ten  years.  "  Handbuch  der  Gyn. ,"' 
vol.  ii,  p.  84. 


544  Diseases  of  the  Urinary  Tract 

result  of  a  pelvic  abscess  which  opens  both  into  the  bowel  and 
into  the  bladder. 

Ureteral  fistulre  more  frequently  follow  gynecological  oper- 
ations than  labor.  They  are  naturally  small  in  size  and  are 
usually  situated  in  the  vaginal  vault,  though  they  may  empty 
into  the  uterus. 

Diagnosis. — It  is  usually  easy  to  recognize  a  vesicovaginal 
"fistula.  There  is  incontinence  of  urine  and  the  orifice  in  the 
vesicovaginal  septum  is  visible  by  the  aid  of  a  Sims'  speculum. 
If  the  fistula  is  small,  a  uterine  sound  introduced  in  the  bladder 
may  be  made  to  emerge  from  the  orifice  in  the  vagina,  or  the 
sound  being  held  in  the  bladder,  a  surgeon's  probe  may  be  in- 
serted into  every  suspicious-looking  depression  in  the  anterior 
vaginal  wall  until  the  communication  is  discovered  and  the  two 
instruments  grate  on  one  another.  Colored  fluid  (a*  weak  per- 
manganate solution  or  sterilized  milk)  may  be  injected  in  the 
bladder  and  will  be  seen  oozing  out  of  a  small  opening  on  the 
anterior  vaginal  wall. 

A  cervical  fistula  may  be  detected  by  separating  the  lips  of 
the  cervix  and  inspection,  by  the  tip  of  an  intravesical  sound 
protruding  into  the  cervical  canal,  or  by  injecting  the  bladder 
and  seeing  the  fluid  emerge  fi'om  the  cervi.K,  which  is  exposed  by 
a  bivalve  vaginal  speculum. 

A  ureteral  fistula  may  be  recognized  by  the  fact  that  part  of 
the  urine  is  voided  naturally  while  part  constantly  dribbles  away  ; 
by  sounding  with  a  metal  ureteral  catheter  every  little  indenta- 
tion in  the  vaginal  vault  or  cervical  canal  until  the  ureter  is 
catheterized  and  the  urine  flows  from  the  lower  end  of  the  cath- 
eter drop  by  drop  or  by  administering  methyl  blue  by  the  mouth, 
draining  the  bladder  with  a  rubber  tube,  and  packing  the  vagina 
tightly  with  gauze.  If  there  is  a  ureteral  fistula  the  deepest  por- 
tion of  the  packing  will  be  most  intensely  stained. 

An  enterovesical  or  a  colovesical  fistula  is  recognized  by  a 
microscopical  examination  of  the  urine,  which  shows  food  par- 
ticles and  feces.  "A  fecal  odor  to  the  urine  is  not  always  pres- 
ent and  does  not  always  denote  a  communication  with  the 
bowel"  (Fritsch).  An  ingenious  method  of  diagnosticating  these 
fistulae  was  demonstrated  by  Noble  after  Senn  had  discovered  the 
hydrogen  gas  test  for  fecal  fistulas.  A  catheter  was  inserted  in 
the  urethra,  the  bowel  was  inflated  with  hydrogen,  and  the  gas 
was  ignited  as  it  escaped  from  the  end  of  the  catheter. 

Treatment. — There  is  always  a  chance  of  a  vesicovaginal 
fistula  healing  spontaneously.  According  to  Fritsch,  there  are 
three  methods  by  which  a  spontaneous  cure  is  effected  :  First, 
by  granulation  tissue    filling    the  opening  and  eventually  clos- 


Treatment  of  Urinary  Fistulae 


545 


m 


ing  it.  This  result  is  favored  by  irrigation  of  the  vagina  to 
keep  it  clean,  by  draining  the  bladder  after  the  fifth  day  post- 
partum with  a  Skene's  catheter  or  rubber  tube,  and  by  touching 
the  edges  of  the  fistula  with  a  little  nitric  acid  to  promote  exu- 
berant granulation,  although  the  application  of  the  caustic  had 
better  be  omitted  if  the  case  is  apparently  pursuing  a  favorable 
course.  Second,  by  an  inflammatory  infiltration  and  swelling  of 
the  vaginal  walls,  which  approximate  the  edges  of  the  fistula  and 
keep  them  close  together  until  union  is  secured  ; 
and,  third,  by  cicatrization,  which  in  the  course  of 
three  months  may  close  an  opening  as  large  as  a 
silver  dollar. 

The  operative  treatment  should  be  postponed 
until  at  least  three  months  after  labor,  to  allow  for 
the  chance  6f  spontaneous  closure,  to  obtain  firmer 
tissue  for  the  plastic  surgery,  and  to  secure  as  great 
a  contraction  of  the  fistula  as  possible. 

The  vagina,  bladder,  and  vulva  should  be  ren- 
dered as  healthy  as  possible  by  sitz-baths  and  irri- 
gations with  boracic  acid  and  weak  permanganate 
solutions.  If  the  fistula  is  caused  by  a  foreign 
body,  such  as  an  embedded  pessary  or  a  stone, 
sufficient  time  must  be  allowed  after  its  removal 
to  secure  a  complete  healing  over  of  ulcerated  sur- 
faces and  a  cessation  of  purulent  discharge. 

General  anesthesia  is  usually  required.  Local 
anesthesia  is  not  to  be  recommended. 

The  dorsal  position,  with  raised  buttocks  and 
limbs  fixed  in  leg  holders  and  stirrups,  is  most 
suitable  for  the  majority  of  cases.  In  fistulae  deep 
within  the  genital  canal,  Sims'  position  or  the  knee- 
chest  posture  may  be  necessary.  For  the  latter 
a  specially  constructed  wedge-shaped  cushion  is 
the  most  convenient  and  safest  support.  Etheriza- 
tion is  perfectly  possible  in  this  position.  Sims' 
specula  with  blades  of  varying  length  and  breadth 
and  lateral  vaginal  retractors  ;  scissors,  curved  on 
the  flat,  sharp  pointed,  with  thin  blades  ;  knives  set  at  an  angle  on 
the  shaft,  as  well  as  an  ordinary  narrow-bladed  scalpel ;  bullet- 
forceps  ;  two  Ulrich's  tenacula  and  single  tenacula ;  a  rat-toothed 
tissue  forceps  ;  a  needle  holder  and  assorted  needles,  most  of 
which  should  be  full  curved,  round-pointed,  and  delicate,  and  some 
of  which  should  have  the  fish-hook  curve,  are  the  instruments 
required.  The  suture  material  should  be  silkworm-gut,  formalin 
catgut,  and  fine  silk.  The  last  is  recommended  most  highly  by 
35 


Fig.  463-— 
Ulrich's  tenac- 
ulum. 


546 


Diseases  of  the  Urinary  Tract 


Fritsch,  whose  experience  with  these  operations  is  greater  than 
that  of  any  other  surgeon.^  The  field  of  operation  is  exposed 
by  pulling  down  the  cervix  with  a  strong  silk  ligature,  transfixing 
its  lips  at  a  sufficient  height  above  the  external  os  to  prevent  the 
ligature  cutting  out  (i  centimeter);  by  vaginal  retractors  or  by 
fixing  the  labia  with  bullet  forceps  and  pulling  them  apart.  It 
is  occasionally  necessary  to  dilate  the  vaginal  canal  narrowed 
by  cicatrization,  and  to  cut,  stretch,  or  tear  cicatricial  bands 
obstructing  access  to  the  fistula.  The  shape  and  extent  of  the 
denudation  are  governed  by  the  situation  and  extent  of  the 
fistula.      The  length  of  the  wound  should,  if  possible,  run  across 


1'  ig.  464. — Denudation  for  a  small 
fistula  (P>itsch). 


Fig.   465. — Denudation   for  fistula  with  ten- 
sion on  the  edges  of  the  wound  (Fritsch). 


Fig.  466. — Insertion  of  the  suture  after  the  denudation  :  a,  a,  Suture  just  above  the 
vesical  mucosa;  l>,  b,  suture  emerging  in  the  vagina  (Fritsch). 


the  vagina,  as  the  vaginal  walls  are  more  easily  approximated 
from  above  downward  than  transversely.  For  small  fistulae 
a  long  linear  incision  having  the  fistula  as  .its  mid-point,  with 
a  broad  denuded  surface  secured  by  a  flap-splitting  dissection, 
is  the  best.  For  larger  fistulae  the  denudation  represented 
in  figures  465  and  466  is  preferable.  The  breadth  of  the  de- 
nudation should  never  be  less  than  i  to  2  centimeters.  If  one 
edge  of  the  fistula  is  adherent  to  the  pubis  or  so  fixed  by  cica- 
trices that  it  is  immobile,  a  thick  flap  may  be  prepared  from  the 
vaginal  wall  with   a  broad  base,  with  the   least  torsion   of   the 

^  I   have  usually  employed  a  double  tier  running  suture  of  catgut,  reinforced  by 
interrupted  sutures  of  silkworm-gut,  shotted. 


Treatment  of  Urinary  Fistulce 


547 


pedicle  possible,  and  larger  in  all  its  dimensions  than  the  denuded 
surface  it  is  designed  to  cover.  The  flap  is  fixed  by  buried 
sutures  of  fine  catgut,  the  edges  of  the  mucosa  being  united  by 
superficial  stitches  of  silk  or  silkworm-gut.  A  flap  may  be  pre- 
pared by  a  semicircular  incision  with  its  base  alongside  the  fistula  ; 
it  is  turned  on  its  base  so  that  the  vaginal  mucous  surface  projects 
into  the  bladder  ;  after  the  edges  are  fixed  by  fine  catgut  in  the 
denuded  edges  of  the  fistula,  the  raw  surface  is  covered  by  the 
approximation  of  the  vaginal  mucous  membrane  surrounding  it 
(Martin). 

Ferguson  proposes  a  circular  incision  around  the  fistula  3 
to  6  millimeters  from  its  margin,  down  to  the  vesical  wall.  The 
vaginal  flap  is  dissected  loose,  turned  inward,  and  its  free  edges 
united  with  fine  formalin  gut,  thus  closing  the  fistula.  The  raw 
surfaces  left  in  the  vagina  are  approximated  by  interrupted 
sutures. 

It  may  be  impracticable  to  close  a  large,  irregularly  shaped 
fistula  at  one  sitting.      The  most  easily 
approximated  edges   are  united  at  one 
operation    and    the    remainder    of   the 
opening  is  closed  subsequently. 

The  anterior  lip  of  the  cervix  may 
be  used  as  a  plug  to  cover  in  a  con- 
siderable defect  in  the  bladder-wall. 
The  author  has  thus  closed  a  fistula 
admitting  four  fingers,  due  to  the  ulcer- 
ation of  a  neglected  pessary  through 
the  vesicovaginal  septum.  The  lateral 
extremities  of  the  fistula  were  closed 
in  the  ordinary  way  and  the  denuded 
vaginal  portion  of  the  cervix  was  fastened  in  the  center  of  the 
wound,  where  a  defect  existed  too  extensive  to  be  covered  by 
vaginal  flaps. 

In  closing  fistulse  running  a  considerable  distance  trans- 
versely, care  must  be  exercised  to  locate  the  ureteral  orifices 
which  otherwise  might  be  buried  in  the  denuded  surface  or 
occluded  by  a  suture. 

In  suturing  a  denuded  area  around  or  a  transplanted  flap 
over  a  vesical  fistula,  the  needle  must  not  penetrate  the  vesical 
mucosa.  If  it  does,  an  intravesical  hemorrhage  will  probably  re- 
sult in  a  failure  of  the  operation  or  the  suture  tract  may  develop 
into  another  fistula.  Acquired  atresia  of  the  vagina  is  a  method  of 
spontaneous  cure  not  infrequently  seen.  If  the  patient  has  passed 
the  menopause,  she  remains  comfortable  ;  but  if  she  menstruates 


Fig.  467. — Apposition 
when  the  denudation  is  prop- 
erly made  and  the  suture  cor- 
rectly inserted  (Fritsch). 


548 


Diseases  of  the  Urinary  Tract 


into  the  bladder,  there  may  be  severe  distress  at  the  periods  ;  ^ 
and  if  the  lower  portion  only  of  the  vaginal  canal  is  closed,  a 
sac  exists  beneath  the  level  of  the  fistula  in  which  blood,  pus, 
and  decomposed  urine  collect.  It  is  occasionally  impossible  to 
close  a  serious  defect  in  the  posterior  wall  and  base  of  the  bladder. 
In  such  cases  a  colpoclcisis  is  justifiable,  if  the  precaution  is  taken 
to  close  the  canal  up  to  the  level  of  the  fistula,  leaving  no 
vaginal  sac  below  for  the  retention  of  decomposed  urine  and 
menstrual  discharge. 

Fritsch  has  closed  a  fistula  by  denuding  the  anterior  surface 


Fig.   468. 


-Flap-formation  as  suggested 
by  Ferguson. 


Fig.    469. 


-Flap   turned    in    and  vesical 
opening  closed. 


of  the  posterior  lip  of  the  cervix  in  a  case  of  defect  of  the  ante- 
rior lip  and  implanting  the  posterior  lip  in  the  vesical  opening. 
The  woman  menstruated  into  the  bladder,  but  remained  com- 
fortable for  years. 

To  close  the  vagina  (colpocleisis),  a  circular  denudation  is 
made  around  the  whole  canal  2  centimeters  broad,  at  a  sufficient 
height  to  preclude  the  formation  of  a  sac  below  the  level  of  the 
fistula  ;  a  row  of  interrupted  sutures  across  the  vagina,  inserted 
fi'om  before  backward,  closes  the  canal.  In  difficult  cases  of  ex- 
tensive  fistulas   deep   within  the   vagina,  and   of   fixation   of  the 

'  I  have  at  present  under  observation  a  case  of  the  kind  :  vesicovaginal  fistula, 
acquired  atresia  of  the  vagina,  a  retroflexed  and  fixed  uterus  with  salpingo-oophoritis. 
There  is  menorrhagia  and  severe  dysmenorrhea  due  to  the  passage  of  clots  from  the 
urethra.      I  intend  to  perform  hysterectomy. 


Treatment  of  Urinary  Fistulae 


549 


bladder  by  cicatricial  adhesions,  the  following  procedures  have 
been  advocated  and  adopted  : 

Incision  into  the  anterior  bladder-wall  by  suprapubic  cystot- 
omy in  the  Trendelenburg  posture  and  closure  of  the  fistula  from 
above,  silk  ligatures,  if  they  are  used,  being  left  long  and  led  out 
of  the  urethra,  whence  they  are  removed  by  traction  after  they 
have  cut  through  the  tissue  ;  or  buried  catgut  sutures  may  be 
emplo\'ed  (Trendelenburg). 

A  transverse  incision  over  the  pubis,  freeing  the  bladder,  and 
closure  of  the  fistula  from  the  vagina  (Fritsch). 

Separation  of  the  vagina  from  the  bladder  around  the  fistula, 


Fig.  470. — The  vesical   opening  closed  and   sutures  inserted  to  unite   the  vaginal 

walls. 


closure  of  the  opening  in  the  bladder,  and  a  separate  closure  of 
the  vaginal  wound  as  in  anterior  colporrhaphy  (Winternitz, 
Mackenrodt). 

Opening  Douglas's  pouch,  retroverting  the  uterus  into  the 
vagina,  using  its  posterior  surface  (which  becomes  anterior  in  the 
complete  retroversion)  as  a  plug  to  fill  in  a  large  defect  in  the 
vesicovaginal  septum,  and  making  an  artificial  os  in  the  fundus  to 
allow  the  escape  of  menstrual  discharge  (Freund). 

If  the  urethra  is  absent  or  partly  destroyed,  its  restoration  is 
always  doubtful.  The  most  hopeful  plan  is  to  prepare  a  flap  of 
mucous  membrane  as  thick  as  possible  from  one  side,  to  turn  it 
inward  so  as  to  bring  the  mucous  surface  within  the  newly  made 


550  Diseases  of  the  Urinary  Tract 

canal,  and  to  fasten  it  in  a  denuded  area  on  the  opposite  side. 
The  new  urethra  should  be  established  before  the  vesical  fistula 
is  closed. 

Fortunately,  continence  may  be  established  without  the  pres- 
ence of  a  urethra,  by  leaving  a  narrow  orifice  at  the  neck  of  the 
bladder.  This  was  accomplished  in  one  of  the  author's  cases 
after  several  futile  attempts  to  construct  a  new  urethra,  which  was 
entirely  lacking  directly  back  of  the  external  meatus. 

If  there  is  such  a  serious  defect  of  urethra  and  base  of  blad- 
der that  no  plastic  operation  succeeds  in  restoring  even  partial 
continence,  colpocleisis  and  a  rectovaginal  fistula  may  make  the 
patient's  condition  endurable.  But  if  there  is  a  cystitis  at  the 
time  of  operation,  the  result  may  be  fatal  from  an  exacerbation 
of  the  inflammation  and  infection  of  the  ureters  and  kidneys. 
Indeed,  there  is  always  danger  after  such  an  operation  of  pyelo- 
nephritis, though  occasionally,  as  in  one  of  Fritsch's  cases,  the 
patient  remains  comfortable  and  well  for  years. 

The  rectovaginal  fistula,  admitting  a  forefinger,  should  be 
made  by  a  transverse  incision  just  above  the  sphincter  ani,  the 
vaginal  and  rectal  mucous  membranes  being  united  by  interrupted 
sutures  of  catgut.  The  vaginal  orifice  is  then  closed.  A  double 
rubber  drainage-tube  is  inserted  through  the  fistula,  and  during 
the  patient's  convalescence  the  vesicovaginal  pouch  is  frequently 
irrigated  with  a  boracic  acid  solution. 

The  most  important  question  to  decide  in  the  after-treatment 
of  a  vesicovaginal  fistula  operation  is  whether  to  resort  to  drain- 
age of  the  bladder  or  to  catheterization.  After  trying  both  plans, 
I  prefer  catheterization  every  four  hours  ;  but  Fritsch,  from  a 
much  larger  experience,  unreservedly  recommends  drainage  by 
the  following  plan  :  After  the  operation,  the  bladder  is  injected 
with  water  to  test  its  impermeability.  A  rubber  tube  is  then 
inserted  in  the  urethra  until  the  water  flows  out — that  is,  until 
its  end  just  passes  the  internal  sphincter.  This  tube  is  fastened 
to  the  mucous  membrane  of  the  external  meatus  by  a  few  fine 
sutures  and  is  long  enough  to  be  led  into  a  vessel  between  the 
patient's  knees.  Skene's  retention  catheter  is  likely  to  get 
stopped  up  and  to  prove  an  irritant  to  the  bladder,  so  that  the 
rubber  tubing  is  preferable. 

The  vagina  is  lightly  packed  with  iodoform  gauze.  The  tube 
and  the  packing  are  removed  on  the  seventh  or  eighth  day  and 
at  the  same  time  the  stitches  are  removed,  or,  if  fine  silk  has  been 
used,  they  may  be  left  to  come  away  of  themselves. 

If  a  ureter  has  been  included  in  one  of  the  .stitches,  there  are 
the  symptoms  of  deficient  urinary  secretion,  rapid  pulse,  pain  in 
the   back,    a   tendency   to   somnolence,   and   sometimes,   though 


Treatment  of  Ureteral  Fistiilae  551 

rarely,  high  fever.  There  are  two  courses  open  to  the  operator  : 
one  is  to  remove  the  stitches  and  to  do  the  operation  over  again  ; 
the  other  is  to  trust  to  nature  to  overcome  the  difficulty,  which  is 
often  done  by  the  stitch  cutting  through,  by  the  urine  under  pressure 
forcing  its  way  through  the  loop  of  the  ligature,  or  by  the  estab- 
lishment of  a  ureterovaginal  fistula.  Occasionally  the  kidney  on 
the  affected  side  atrophies  and  the  remaining  kidney  performs  the 
work  of  two,  as  after  a  nephrectomy. 

If  there  is  a  persistence  of  incontinence  after  the  operation, 
the  flow  of  urine  may  come  from  a  suture  track,  from  a  failure 
of  union  at  some  part  of  the  wound,  or  from  a  second  fistula  not 
detected  at  the  time  of  the  operation.  The  last  two  conditions 
require  subsequent  operations.  A  small  suture  track  fistula  often 
closes  spontaneously,  and  some  time  should  be  allowed  for  this 
result  before  subjecting  the  patient  to  a  second  operation,  which 
might  be  unnecessary. 

Intravesical  hemorrhage  will  not  occur  after  an  operation 
for  vesicovaginal  fistula  if  the  sutures  are  properly  placed.  If  it 
does,  it  is  an  awkward  complication.  The  bladder  should  be 
washed  out  with  boracic  acid  solution  every  two  hours  to  prevent 
the  formation  of  a  large  clot.  If  a  clot  does  form  in  the  bladder, 
causing  tenesmus,  the  injection  of  pepsin  solution  has  been  rec- 
ommended to  soften  it. 

The  Treatment  of  Ureteral  Fistulae  and  of  Surgical  Injuries  of  the 
Ureters. — There  are  three  kinds  of  surgical  treatment  for  ureteral 
fistulae:  nephrectomy;  a  plastic  operation  in  the  vagina  {colpo- 
2iretero-cystostoiny ,  or  ureteral  anastomosis),  and  an  abdominal  sec- 
tion followed  by  the  junction  of  the  ureter  {celio-iiretero-2ireteros- 
tojuy)  or  its  implantation  in  the  bladder  {celio-iiretero-cystostoniy). 

A  neplirectomy  is  often  the  easiest  way  to  remove  the  dis- 
agreeable symptoms  of  a  ureteral  fistula,  but  it  cannot  be  called 
the  ideal  operation.  There  must  always  be  some  doubt  as  to  the 
adequacy  of  the  remaining  kidney,  and  the  natural  impulse  is  to 
avoid  the  removal  of  such  an  important  organ  unless  it  is  itself 
diseased.  It  must  be  admitted,  however,  that  the  operation  has 
been  repeatedly  performed  with  success.  Several  of  the  women  ^ 
have  subsequently  been  delivered  at  term  without  the  slightest 
disturbance  of  health.  As  in  nephrectomies  for  any  indication, 
the  most  scrupulously  careful  examination  should  be  made  of  the 
secretion  from  the  remaining  kidney,  by  catheterizing  the  ureter 
or  by  vesical  segregators  (Harris'  or  Cathelin's).  If  the  kidney 
corresponding  to  the  ureteral  fistula  shows  evidence  of  pyelo- 
nephritis or  hydronephrosis  there  is  additional  justification  for  its 
removal,  but  it  should  be  remembered  that  both  of  these  con- 

1  Fritsch  reports  3  cases  [loc.  cit.). 


552  Diseases  of  the  Urinary  Tract 

ditions  ha\e  disappeared  after  the  fistula  has  been  closed  by  vagi- 
nal or  abdominal  operations. 

Nephrectomy  should  in  general  be  limited  to  those  cases  in 
which  the  closure  of  the  fistula  has  proved  impracticable  by  both 
the  vaginal  and  abdominal  routes  or  in  which  there  is  marked 
hydronephrosis  or  pyelitis. 

The  operation  may  be  performed  by  a  lumbar  incision  or  by 
the  transperitoneal  method.  The  latter  is  often  easier  for  the 
surgeon,  but  may  not  be  so  safe  for  the  patient.  There  is  no 
necessity  for  the  exsection  of  the  ureter,  and  there  need  be  no 
fear  of  the  regurgitation  of  urine  from  its  lower  fragment.  If 
the  transperitoneal  operation  is  selected,  the  incision  should  be 
made  laterally  through  the  abdominal  wall  directly  over  the 
kidney.  The  posterior  parietal  layer  of  the  peritoneum  is  opened, 
the  kidney  delivered,  and  its  pedicle  (blood-vessels  and  ureter)  is 
tied  with  silk  or  catgut  by  passing  a  pedicle  needle  through  its 
middle,  tying  in  both  directions,  and  then  back  again  around  the 
whole  stump.  This  step  in  the  operation  is  usually  easier  in  the 
transperitoneal  than  in  the  lumbar  operation.  Both  layers  of 
peritoneum  are  closed. 

The  steps  of  the  lumbar  operation  are  the  same  as  those  of 
nephrorrhaphy,  to  be  described  later. 

The  lumbar  incision  should  always  be  preferred  if  there  is 
pyelonephritis  or  perinephritis,  or  if  the  most  perfect  aseptic 
technic  is  impracticable.  Many  operators  accustomed  to  neph- 
rorrhaphy by  this  method  prefer  it  uniformly. 

The  Vaginal  Operations  for  Ureteral  Fistula. — The  first  requi- 
site for  a  successful  plastic  operation  by  the  vagina  is  to  find  the 
upper  end  of  the  ureter  and  its  orifice,  which  it  is  not  always  easy 
to  do.  If  there  is  not  too  much  scar-tissue,  the  ureter  may  be 
dissected  out,  implanted  into  an  incision  made  into  the  bladder, 
and  fastened  in  place  by  several  interrupted  sutures  of  fine 
catgut.  The  vaginal  wound  is  closed  over  the  end  of  the  ureter 
and  the  opening  in  the  bladder  into  which  it  has  been  implanted 
(Parvin,  McArthur).  It  has  sometimes  been  possible  to  sew  the 
mucous  membrane  of  the  bladder  to  the  mucous  membrane  of 
the  ureter  and  so  to  fasten  the  latter  in  place.  The  vaginal 
mucosa,  dissected  back  on  each  side  by  a  flap-splitting  dissection, 
is  united  over  the  ureter  and  the  newly  made  opening  into  the 
bladder. 

Schede's  operation  has  given  on  the  whole  the  best  results  :  a 
vesicovaginal  fistula  is  made  close  by  the  ureteral  fistula,  the 
mucous  membrane  of  the  bladder  and  that  of  the  vagina  being 
united  by  interrupted  sutures  of  catgut ;  an  oval  denudation  is 
made  i  centimeter  wide  around  both  the  ureteral  and  the  vesical 


Operations  for  Ureteral  Fistulae  553 

fistula,  leaving  a  strip  of  unclenuded  membrane  0.5  centimeter 
wide  immediately  surrounding  both  fistulas.  The  denuded  sur- 
faces are  united  by  interrupted  sutures,  thus  directing  the  stream 
of  urine  from  the  ureter  into  the  bladder. 

BandV s  operation  is  only  practicable  if  both  ends  of  the 
ureter  are  discoverable  and  are  normally  patent.  A  ureteral  cath- 
eter is  passed  into  botii  the  lower  and  the  upper  segments  of  the 
ureter,  emerging  from  the  urethra.  A  denudation  is  made  and 
united  as  in  Schede's  operation,  but  without  making  a  vesicovaginal 
fistula.  If  the  catheter  is  fenestrated,  the  whole  bladder  is  drained 
by  it,  or  the  urethra  may  be  drained  by  a  rubber  tube  through 
which  the  ureteral  catheter  passes. 

Mackenrodf  s  operation  is  very  ingenious  and  has  been  suc- 
cessful in  the  few  cases  in  which  it  was  tried.  A  vesicovaginal 
fistula  is  made  near  the  ureteral  fistula.  A  semicircular  thick 
flap  of  vaginal  mucosa  is  dissected  off,  so  that  it  carries  the 
ureteral  opening  in  its  center,  has  its  attached  base  next  to  the 
vesicovaginal  fistula,  and  its  free  edge  away  from  it.  By  turning 
this  flap  over  a  half  circle  on  its  base  it  closes  the  vesicovaginal 
fistula  like  a  lid  ;  it  is  sewed  in  place  by  catgut  sutures,  with  the 
vaginal  mucous  membrane  looking  into  the  bladder  and  so  turn- 
ing the  ureteral  fistula  into  the  bladder.  The  raw  surfaces  left 
by  the  removal  of  the  flap  and  over  the  vesicovaginal  fistula  are 
united  with  interrupted  sutures,  or  are  allowed  to  granulate. 

Dudley s  Operation,  as  Reynolds  ^  says,  is  a  crude  procedure, 
but  has  succeeded  when  other  plans  have  failed.  A  sharp-pointed 
artery  or  other  similar  forceps  is  passed  into  the  urethra  ;  a  vesi- 
covaginal opening  is  made  ;  one  blade  of  the  forceps,  which  is 
opened  for  the  purpose,  is  pushed  out  of  the  incision  in  the  blad- 
der ;  the  renal  end  of  the  ureter  is  threaded  on  it ;  the  handles 
of  the  instrument  are  closed  and  tied,  thus  clamping  the  end  of 
the  ureter  to  the  bladder-wall.  The  forceps  is  lightly  pulled 
upon  after  eight  or  ten  days.  If  it  does  not  come  away  it  is 
opened  and  extracted. 

The  Abdominal  Operation  for  Ureteral  Fistula  or  Injury. — If 
the  ureter  is  injured  during  an  operation,  it  may  be  repaired  in 
several  ways  :  If  the  incision  is  linear  or  fails  to  sever  the  ureter 
completely,  the  wound  may  be  repaired  by  fine  catgut  sutures, 
mattress  or  interrupted,  with  considerable  certainty  of  success. 
If  the  ureter  is  completely  severed,  is  fenestrated  or  badly 
crushed,  as  by  clamp  forceps,  it  may  be  re-joined  by  an  end-to- 
end  anastomosis  (Tauffer,  Bovee)  ;  by  an  end-to-end  (Poggi)  ro 
a  lateral  invagination  (Van  Hook's  uretero-ureterostomy)  ;  or  by 
a  lateral  anastomosis.    In  the  first,  a  section  of  a  ureteral  catheter 

1  "Boston  Med.  and  Surg.  Jour.,"  1901,  p.  84. 


554  Diseases  of  the  Urinary  Tract 

is  pass.ed  into  both  segments  of  the  ureter,  with  a  silk  hgature 
tied  around  its  middle,  to  recover  it  by,  if  it  should  slip  down 
the  lower  portion  of  the  canal.  Interrupted  sutures  of  fine  silk 
or  formalin  catgut  are  passed  through  the  walls  of  the  two 
■ends  of  the  ureter  ;  before  the  knots  are  tied,  the  catheter  is  with- 
drawn. 

Van  Hook's  lateral  invagination  is  the  most  reliable  opera- 
tion. The  upper  end  of  the  lower  segment  of  the  ureter  is  ligated ; 
a  linear  incision  is  made  through  its  wall  below  the  ligature 
twice  as  long  as  the  diameter  of  the  ureter  ;  the  upper  segment 
is  implanted  into  this  incision  and  is  fastened  by  fine  sutures  at 
both  ends  of  the  wound  ;  the  edges  of  the  incision  are  then  care- 
fully sewed  to  the  ureteral  wall  passing  between  them,  so  that  the 
opening  is  securely  closed.  Bovee  in  1897  collected  12  cases 
of  ureteral  anastomosis.  If  a  junction  of  the  two  ends  of  a 
.severed  ureter  is  impossible,  as  in  a  case  of  old  injury,  extensive 
destruction  of  tissue,  or  the  removal  of  a  considerable  por- 
tion of  the  ureter  in  the  wall  of  a  cyst  or  a  fibroid  tumor, 
implantation  of  the  upper  segment  into  bladder  (celio-uretero- 
cystostomy)  is  necessary.  This  may  be  done  by  a  transperitoneal 
or  an  extraperitoneal  operation.  In  the  former  the  peritoneum 
•over  the  ureter  is  incised,  usually  in  the  neighborhood  of  the 
bifurcation  of  the  iliac  arteries  ;  the  ureter  is  dissected  free,  care 
being  taken  not  to  isolate  it  too  extensively,  on  account  of  danger 
to  its  nutrition.  An  incision  is  made  into  any  portion  of  the 
bladder-wall,  which  the  ureter  reaches  without  tension  ;  the  end 
of  the  ureter  is  inserted  into  the  opening  so  that  it  projects  some- 
what into  the  bladder ;  the  edges  of  the  wound  in  the  latter  are 
carefully  sewed  to  the  wall  of  the  ureter  by  interrupted  or 
mattress  sutures,  and  its  angles  are  closed  by  separate  sutures. 
Penrose  recommends  splitting  the  end  of  the  ureter,  putting  a 
mattress  suture  in  each  lip,  and  passing  each  end  of  the  mattress 
sutures,  rethreaded  on  a  fine  needle,  through  the  bladder- wall, 
tying  them  on  the  peritoneal  surface  of  the  bladder.  This  plan 
prevents  occlusion  of  the  ureteral  orifice  and  precludes  the  ureter 
slipping  out  of  the  bladder. 

There  are  disadvantages  in  the  transperitoneal  operation. 
Failure  may  mean  fatal  peritonitis,  in  spite  of  drainage  ;  and  the 
band  of  isolated  ureter  traversing  the  pelvic  and  lower  abdominal 
cavities  may  cause  intestinal  complications. 

The  extraperitoneal  operation  is  the  ideal  one,  if  it  is  prac- 
ticable. The  implantation  of  the  ureter  in  the  bladder  by  a  vagi- 
nal operation  has  been  described  (p.  552).  In  an  abdominal 
operation  it  may  be  possible  to  reach  the  upper  segment  by 
incising  the  anterior  layer  of  the  broad  ligament  and  the  vesico- 


operations  for  Ureteral  Fistulae  555 

uterine  pouch  and  to  implant  the  ureter  under  the  peritoneal 
covering  of  the  latter. 

Witzel  proposes  to  free  the  ureter  as  in  the  transperitoneal 
operation,  carrying  its  end  by  forceps  around  the  brim  of  the 
pelvis  under  the  peritoneum  and  bringing  it  forward  above  the 
anterior  parietal  peritoneum.  Both  incisions  in  the  peritoneum 
are  closed  and  the  operation  is  concluded  extraperitoneally  by 
implantation  of  the  ureter  in  the  bladder,  the  ureter  being  cut 
obhquely  so  that  its  end  is  a  point,  the  bladder  being  incised 
obliquely  so  that  the  implanted  ureter  runs  some  distance  in  its 
wall.  It  is  necessary  to  fasten  the  bladder- wall  to  the  pelvic  con- 
nective tissue  by  catgut  sutures  to  avoid  tension  on  the  implanted 
ureter.  «Mackinrodt  modifies  this  procedure  by  making  his  ab- 
dominal incision  at  the  outer  edge  of  a  rectus  muscle  ;  separat- 
ing the  peritoneum  to  the  bifurcation  of  the  iliac  artery,  bringing 
the  end  of  the  ureter  forward  above  the  peritoneum,  puncturing 
the  bladder  from  within  by  a  trocar,  and  drawing  the  end  of  the 
ureter  into  it.  If  the  ureter  is  so  much  shortened  that  its  upper 
portion  can  not  be  made  to  reach  the  bladder  without  too  much 
tension,  the  following  ingenious  plans  have  been  proposed  to 
splice  it :  The  two  ends  of  the  ureter  are  brought  out  on  the 
abdominal  skin  and  fastened  there  ;  after  the  wound  has  healed, 
a  tube  of  skin  is  made  between  the  two  ureteral  orifices  by 
parallel  incisions,  and  uniting  the  free  edges  of  the  skin  ;  the 
tube  is  depressed  and  covered  over  by  uniting  the  outer  edges 
of  the  parallel  incisions  (Rydygier).  A  diverticulum  is  con- 
structed from  the  anterior  bladder-wall,  into  which  the  upper  end 
of  the  ureter  is  implanted  (Van  Hook,  Boari,  Casati).  The  ureter 
is  spliced  by  a  hollow,  decalcified  turkey's-wing  bone  sewed  in 
the  ureter  and  the  bladder  (Van  Hook).  The  ureter  is  spliced 
by  a  segment  of  small  intestine,  separated  from  the  bowel  which 
is  joined  by  an  end-to-end  anastomosis  ;  the  segment  of  gut  is 
left  attached  to  its  mesentery  and  is  closed  by  sutures  at  both 
ends.  The  two  ends  of  the  ureter  are  implanted  in  the  segment 
of  bowel  (Bacon).  The  appendix  is  used  to  splice  the  ureter 
(Giannettasio).  The  ureter  is  implanted  in  the  Fallopian  tube 
(D'Urso  and  Fabii).  These  propositions  have  been  theoretical 
or  else  the  result  of  experiments  on  dogs.  ^ 

As  in  all  intra-abdominal  operations  on  the  ureters  and  bladder, 
the  Trendelenburg  posture  is  essential,  and  gauze  drainage  after- 
ward is  necessary  in  case  the  closure  of  the  bladder  or  junction 
of  the  ureters  proves  imperfect. 

^  Henry  Morris,  "  Surgical  Diseases  of  the  Kidney  and  Ureter,"  vol.  ii,  p.  608, 
and  Nicholson,  "  Treatment  of  Severed  Ureters,"  "  Amer.  Jour.  Med.  Sci.,"  April, 
1902. 


556  Diseases  of  the  Urinary  Tract 


MALFORMATIONS  AND  DISEASES  OF  THE  URETHRA. 
Total  Defect  of  the  Urethra. — As  the  result  of  arrested  de- 
velopment the  urethra  is  absent.  The  neck  of  the  bladder  may 
also  be  absent,  the  vagina  and  bladder  being  a  common  canal. 
There  may  be  defective  development,  also,  of  the  clitoris  and 
nymph  ae. 

Partial  Defect  of  the  Urethra. — The  lower  portion  of  the 
urethra  may  be  absent  (hypospadias);  sometimes  only  the  lower 
wall,  sometimes  the  whole  canal  in  its  lower  part.  There  may  be 
a  defect  in  the  upper  part  of  the  lower  urethral  wall  just  below 
the  vesical  sphincter. 

Atresia  urethras  usually  affects  the  upper  portion.  The 
canal  may,  however,  be  closed  throughout  its  whole  length. 

There  may  be  a  duplicity  of  the  urethral  canal,  the  external 

orifices  lying  side  by  side,  the  internal  one  above  the  other  (Fiirst). 

The  symptom   of   urethral    malformation   is    either  retention 

of  urine  or  incontinence. 
Grave  defects  are  often  in- 
compatible with  extra-uter- 
ine existence.  The  diffi- 
culty in  atresia  or  defect  of 
the  urethra  is  sometimes 
spontaneously  overcome  by 
Fig.  471. —Skene's  urinal  cup-pessary:     a   patent   urachus  and   the 

a  represents  the  posterior  portion  which  sur-       discharge  of  Urine  from  the 
rounds   the   cervix   uteri;   b,  the   cup;  and  c,       ,,»„u;i;^,,„         t„     „^.^^    .«„i 

,,    .  1       1,-  u  ^-u      •     r       .1  umbnicus.      In    some   mal- 

the  tube  which  conveys  the  urine  from  the  cup 

to  the  urinal.  formations,   such   as  hypo- 

spadias, there  may  be  no 
symptoms  at  all.  The  kind  and  degree  of  malformation  are 
recognized  by  inspection,  either  direct  or  through  the  urethro- 
scope; by  palpation,  and  by  the  use  of  a  sound. 

Treatment. — Atresia  requires  operation.  The  region  of  the 
neck  of  the  bladder  is  punctured  with  a  trocar  or  is  opened  by  a 
linear  incision,  the  latter  enabling  the  patient  to  hold  urine  better 
than  the  former.  Sewing  the  vesical  mucous  membrane  to  that 
of  the  vagina  and  the  use  of  bougies  are  necessary  to  keep  the 
opening  patulous. 

The  defects  of  the  urethra  resulting  in  incontinence  may  be 
remedied  by  plastic  operations  such  as  are  required  for  vesical 
fistulae;  may  be  treated  by  pressure  upon  the  lower  vesical  wall 
with  a  specially  constructed  instrument  on  the  principle  of  a 
globe  pessary  with  external  support,  or  the  patient  may  be  made 
comparatively    comfortable    with    an    intravaginal    cup,   Skene's 


Urethritis  557 

urinal  cup-pessary  with  a  rubber  tube  attached  to  a  rubber  bag 
fastened  around  one  tiiigh. 

Urethralgia  is  pain  in  the  urethra  without  organic  disease  or 
anatomical  alteration  of  an}'  kind,  except  a  slightl)'  exaggerated 
prominence  of  tlie  papilla;.  It  occurs  in  neurotic  women  and  is 
probably  a  pure  neurosis.  Local  treatment  only  serves  to  fasten 
the  patient's  attention  on  the  condition  and  to  aggravate  or  pro- 
long it.  The  rest  cure,  change  of  air  and  scene,  tonics,  exercise 
in  the  open  air,  promise  better  results  than  local  applications. 

Urethritis  in  the  female  is  almost  invariabh'  due  to  gonor- 
rhea, although  it  is  often  difficult  or  impossible  in  a  chronic  case 
to  prove  conclusively  the  specific  infection.  In  consequence  of 
the  short  length  and  straight  course  of  the  canal,  gonorrheal 
urethritis  in  the  female  is  of  shorter  duration  and  is  much  less 
troublesome  to  the  patient  than  the  same  affection  in  the  male. 

In  acute  and  in  many  chronic  cases  pus  may  be  pressed  out 
of  the  urethra  by  passing  the  tip  of  the  forefinger  from  the  neck 
of  the  bladder  to  the  external  meatus.    Gonococci  may  be  present 
in  the  pus,  but  their  absence  does  not 
exclude  the  gonorrheal  origin  of  the 
inflammation.     The   meatus   may  be 
irritated  and  inflamed,  and  there  may 
be  additional  evidence  of  the  specific  ^.  t-  •     , ,         ,    , 

,  r    1        •    n  ■  •         1  Fi?-  472- — Fritsch  s  urethral 

character  of  the  mflammation  m  the     canuk ;  to  be  attached  to  a  hypo- 
openings  of  Skene's  glands,  the  vulvo-      dermic  syringe, 
vaginal  glands  and  other  portions  of 

the  genital  tract.  The  urethral  mucous  membrane  seen  through 
the  urethroscope  is  reddened,  thickened,  and  flaked  with  mucopus, 
in  an  acute  case.  In  a  chronic  inflammation  the  same  appearance 
is  seen  in  spots  separated  by  healthy  mucous  membrane.  In 
these  cases  also  granular  erosion  may  be  seen  here  and  there  or 
along  the  whole  course  of  the  canal.  In  posterior  urethritis  in 
the  female  there  may  be  fissures  or  cracks  in  the  urethral  mem- 
brane and  within  the  sphincter  of  the  bladder,  often  hidden  in 
the  swollen  and  reddened  mucosa,  but  displayed  as  the  end  of 
the  urethroscope  is  withdrawn  from  the  bladder. 

The  patient  complains  of  a  burning  sensation  on  urination. 
There  may  be  frequent  micturition  and  vesical  tenesmus,  but  the 
latter  symptoms  indicate  involvement  of  the  bladder,  and  are  due 
to  cystitis  and  not  to  urethritis. 

The  treatment  of  an  acute  case  is  rest  in  bed ;  a  milk  diet ; 
large  draughts  of  water  ;  the  administration  by  the  mouth  of 
urotropin  (5  grains)  and  salol  (5  grains)  alternately  every  three 
hours,  and  the  irrigation  of  the  urethra  once  or  twice  daily  through 
a  Skene's  reflux  catheter  with  a  5  per  cent,  argyrol  solution.     In 


55S  Diseases  of  the   Urinary  Tract 

chronic  cases  the  ingenuity  and  patience  of  the  physician  may  be 
taxed  severely.  The  following  remedies  should  be  tried  :  Injec- 
tion into  the  urethra,  by  a  Fritsch's  tube,  of  argyrol  solutions, 
20  to  50  per  cent. ;  pure  ichthyol ;  solution  of  sulphate  of  zinc,  2 
parts,  tannin,  0.5  part,  water,  500  parts;  solutions  of  ichthargen, 
I  :  2000  ;  nitrate  of  silver  solution,  i  :  4000 ;  formalin  solution, 
I  :  5000  ;  introduction  of  Finger's  ointment  (potas.  iodid,  5iss  ; 
iodin,  gr.  xv ;  ol.  oliv.,  foiss ;  lanoHn,  Siij)  by  a  corrugated 
sound,  washed  out  after  five  to  ten  minutes  ;  slitting  up  Skene's 
ducts  and  several  other  follicles  in  their  neighborhood  with  a 
small  knife  and  destroying  their  interior  with  an  electrocautery 
needle  after  cocainization  ;  applying  pure  carbolic  acid  or  nitrate 
of  silver  solution,  5j-f5j  to  the  most  inflamed  areas  or  to  the 
Avhole  urethral  canal  through  a  urethroscope  ;  introduction  of  an 
emulsion  of  subnitrate  of  bismuth  and  castor  oil,  equal  parts  ;  in- 
sertion of  bacilli  of  cacao  butter  impregnated  as  densely  as  pos- 
sible with  subgallate  of  bismuth  ;  dilating  the  urethra  with  sounds 
or  the  sphincter  with  the  two-branched  uterine  dilator  (for  pos- 
terior urethritis  and  fissures).  The  success  of  any  treatment  may 
demand  an  artificial  vesicovaginal  fistula,  so  that  the  urethra  may 
be  spared  the  constant  irritation  of  micturition. 

Granular  erosion  of  the  urethra  usually  follows  a  chronic 
gonorrheal  urethritis,  though  it  is  said  sometimes  to  arise  spon- 
taneously in  elderly  women.  The  whole  urethra  is  lined  with 
young  columnar  epithelium  ;  the  papillae  are  hypertrophied  ;  the 
mucous  membrane  is  the  color  of  raw  beef,  and  is  extremely 
sensitive.  Urination  is  very  painful.  The  most  successful  treat- 
ment is  cauterization  by  carbolic  acid  and  nitrate  of  silver  solu- 
tion, once  in  eight  to  ten  days  ;  irrigation  of  the  urethra  with 
argyrol  solution,  5  per  cent,  daily,  and  the  use  of  urethral  bacilli 
impregnated  with  subgallate  of  bismuth,  inserted  after  the  irriga- 
tion. The  treatment  is  much  more  speedily  successful  if  a 
vesicovaginal  fistula  is  maintained  until  the  granular  erosion  is 
healed. 

Stricture  of  the  urethra  in  the  female  is  not  nearly  so  com- 
mon as  in  the  male.  It  usually  follows  gonorrheal  urethritis, 
though  it  may  be  the  result  of  injuries  in  childbirth,  the  application 
of  caustics  to  the  canal,  cicatricial  bands  in  the  vagina,  disuse 
in  cases  of  vesicovaginal  fistulae,  or  congenital  stenosis.  The 
stricture  is  usually  in  the  upper  third  of  the  canal  ;  it  may  be  at 
the  external  meatus  or  at  the  vesical  sphincter. 

The  symptoms  are  dysuria  and  frequent  urination. 

The  diagnosis  is  made  by  passing  graduated  sounds  as  in 
the  male  urethra. 

The  treatment  is  gradual  dilatation  with  sounds,  dilatation  with 


Neoplasms  of  the  Urethra 


559 


the  two-branched  uterine  dilator  or  the  division  of  the  stricture 
by  a  urethrotome.  In  cases  of  obstruction  of  the  urethra  due  to 
cicatricial  bands  in  the  vagina,  these  bands  should  be  cut  or  torn 
(p.  143),  in  addition  to  the  passage  of  sounds  in  the  urethra. 
Congenital  stenosis  and  contraction  from  disuse  are  treated  by 
gradual  dilatation  with  bougies. 

Vesico=urethral  fissure  is  a  small,  linear  crack  or  fissure,  in 
the  folds  of  the  mucous  membrane  at  the  vesical  sphincter,  run- 
ning parallel  with  the  long  diameter  of  the  urethra  and  extending 
usually  for  a  third  of  its  length  into  the  bladder.     As  in  a  fissure 


Fig.  473. — Skene's  fissure  probe  and  knife. 


/;/  ano,  the  ulcerated  surface  is  constantly  teased  and  compressed 
by  the  sphincter  muscle  around  it,  causing  frequent  painful  mic- 
turition and  a  constant  burning  sensation  at  the  neck  of  the  blad- 
der. The  fissure  is  plainly  seen  through  a  urethroscope,  which 
is  inserted  into  the  bladder  and  then  slowly  withdrawn  through 
the  sphincter,  which  closes  around  the  end  of  the  instrument. 

The  condition  is   usually  the  result  of  gonorrheal   urethritis, 
but  may  be   due  to  the  passage  of  a  cal- 
culus or  to   urethritis    or  cystitis  from  any 
cause. 

The  treatment  is  dilatation  of  the  urethra 
by  a  sound  three  or  four  sizes  larger  than 
one  that  passes  easily,  touching  the  fissure 
after  wiping  it  off  with  cotton  by  a  small 
probe  point  on  which  nitrate  of  silver  has 
been  fused,  and  incising  it  with  Skene's 
knife.  The  first  two  procedures  usually 
suffice. 

Neoplasms  of  the  Urethra. — Condyl- 
oma, cysts,  myxadenoma,  mucous  polyp, 
angioma,  varices,  phlebectases,  fibroma, 
gumma,  sarcoma,  and  carcinoma  of  the  urethra  have  been  re- 
ported. The  growths  are  easily  seen  through  the  urethroscope. 
To  determine  their  nature  it  may  be  necessary  to  remove  a  piece 
for  microscopical  study.  Pain,  hemorrhage,  dysuria,  dyspareunia, 
are  the  symptoms  of  urethi-al  growths,  with  possibly  the  protru- 
sion of  the  tumor  from  the  meatus. 

Pedunculated  tumors  are  removed  by  polypus  forceps  or  snares. 


Fig.  474. — Skene's 
modification  of  Folsom's 
nasal  speculum. 


50O 


Diseases  of  the  Urinary  Tract 


such  as  are  used  in  the  ear  and  nose.  It  may  be  necessary  to 
ligate  the  pedicle,  to  touch  its  base  after  removal  with  caustic  or 
the  electrocautery  point.  Small  growths  may  be  removed  through 
the  cylindrical  urethroscope.  Large  tumors  are  more  conveniently 
displayed  by  Skene's  urethral  speculum.  Sessile  growths  may 
be  exsected,  if  necessary,  after  incision  of  the  lower  urethral  wall 
or  may  be  destrox-ed  by  the  electrocautery  point.  Malignant 
growths  necessitate  the  excision  of  a  part  or  of  the  whole  urethra. 
Dilatation  or  dilatability  of  the  urethra  is  usually  a  con- 
genital affection.     The  whole  canal  may  be  so  dilatable  as  to  per- 


Fig.  475. — Dilatation  of  middle  third  of  the  urethra  (urethrocele). 


mit  the  insertion  of  the  penis.  Copulation  has  been  practised  in 
this  manner  in  a  number  of  reported  instances.  The  dilatation 
may  be  confined  to  a  portion  of  the  canal  only,  most  often  to  the 
middle  third,  when  the  lower  wall  sags  down  into  a  pouch  {saccu- 
lated urethra,  urethrocele),  from  injury  in  labor  to  its  supporting 
muscle  of  the  urogenital  trigonum. 

The  symptoms  may  be  partial  incontinence  of  urine,  frequent 
and  painful  micturition,  or  dysuria  (in  dilatation  of  the  middle 
third),  but  extreme  dilatability  permitting  coitus  per  iirethram  has 


Dilatation  or   Dilatability  of  the  Urethra        561 

been  observ^cd  with  perfect  continence  and  without  any  incon- 
venience to  tlie  patient. 

The  diagnosis  can  be  made  by  the  insertion  of  sounds  or  the 
finger  in  dilatabihty  of  the  whole  canal,  or  by  the  use  of  a  probe 
in  sacculation  of  the  urethra,  the  point  of  which  can  be  depressed 
into  the  sac  and  felt  through  the  vaginal  wall. 

The  treatment,  if  any  is  required,  is  injection  of  astringents  into 


Fig.  476. — Operation  for  dilatation  of  upper  third  of  urethra  and  relaxation  of 
the  vesical  sphincter,  complicated  by  a  cystocele.  Denudation  of  anterior  wall  of 
vagina  and  excision  of  lower  urethral  wall. 


the  urethra  (tannic  acid),  pressure  upon  the  upper  part  of  the  canal 
by  one  of  the  pessaries  designed  for  cystocele,  or  one  of  the  fol- 
lowing operations  to  narrow  the  canal :  In  sacculation  of  the  ure- 
thra, the  repair  of  the  urogenital  trigonum  muscle  and  an  oval 
excision  of  the  redundant  urethral  wall  closed  by  close-set  in- 
terrupted or  a  tier  catgut  suture  ;  in  dilatation  of  the  upper 
third,  a  linear  incision  in  the  lower  urethral  wall,  excision  of 
36 


562 


Diseases  of  the  Urinary  Tract 


a  part  of  the  urethral  walls  on  both  sides,  and  the  junction 
of  the  wound  with  a  continuous  catgut  or  interrupted  fine 
silk  ligatures  ;  in  dilatation  of  the  lower  third,  excision  of  two  V- 
shaped  pieces  of  mucous  membrane  opposite  one  another,  with 
the  bases  at  the  external  meatus  and  the  apices  within  the 
canal ;   or  drawing  a  fine  cautery  point  along  the  urethral  mucous 


Fig.  477. — Insertion  of  sutures;  two  of  silkworm-gut,  to  unite  the  urethra  and  vesical 
sphincter.      A  running  tier  suture  of  catgut  for  the  cystocele. 


membrane,  through  a  speculum,  in  two  or  more  places  equidistant 
from  one  another,  leaving  strips  of  healthy  membrane  between. 

Injections  of  paraffin  and  vaselin  into  the  periurethral  tissues  has  been  advocated 
and  practised  in  Germany  for  urethral  dilatation  and  incontinence.  Success  is  re- 
ported, Ijut  the  method  is  no  one  that  appeals  to  the  author's  reason,  and  it  is  not 
free  from  risk  of  embolism.      (See  "  Jahresbericht  u.  d.  Jahr  1901,"  p.  364.) 

Displacements  of  the  urethra  occur  in  consequence  of  injury 
to  the  urogenital  trigonum  muscle,  in  association  with  cystocele, 


Prolapse  of  the  Urethra 


563 


inversion  of  the  vagina,  and  prolapsus  uteri.  The  surgical  or 
mechanical  treatment  of  these  conditions  restores  and  maintains 
the  normal  position  of  the  urethra. 

Prolapse  or  inversion  of  the  urethral   mucous   membrane 

occurs  sometimes  in  young  children,  but  oftener  in  elderly 
women.  In  the  former,  however,  it  is  usually  more  exaggerated, 
the  reddened,  thickened,  and  irritated  membrane  projecting  from 


Fig.  478. — The  last  turn  of  the  tier  suture,  uniting  the  edges  of  the  vaginal  mucosa. 
The  two  silkworm-gut  sutures  are  shotted  after  the  continuous  suture  is  tied. 


the  vestibule  and  becoming  partially  strangulated  if  the  meatus  is 
contracted.  In  elderly  women  some  prolapsus  of  the  urethral 
mucous  membrane  is  very  common  ;  it  is  reddened  in  color  or 
of  a  purplish  hue  if,  as  is  often  the  case,  there  is  phlebectasia. 
The  causes  are  urethritis,  ■  cystitis,  vesical  tenesmus,  increased 
intra-abdominal  pressure  (straining  in  labor  and  a  chronic  cough), 
and  general  debility.      It  may  be  inexplicable. 


5^4 


Diseases  of  the  Urinary  Tract 


The  symptoms  are  a  feeling  of  irritation  in  the  part  and  a 
burning  sensation  on  urination. 

The  diagnosis  is  easily  made  by  inspection,  palpation,  and 
the  use  of  a  probe.  The  pouting  membrane  projects  from  the 
meatus  ;  it  can  be  reduced  within  the  urethral  canal  by  taxis, 
and  the  orifice  of  the  canal  is  in  the  middle  of  the  projecting 
tumor. 

The  treatment  is  palliative,  medicinal,  or  radical.  It  may  be 
possible  to  relieve  the  patient's  discomfort  by  replacing  the  pro- 


Fig.  479. — Dislocation  of  the  upper  third  of  the  urethra. 


lapsed  mucous  membrane,  keeping  her  in  bed  for  a  while,  and 
applying  astringents,  tannic  acid,  adrenalin  solution,  or  formalin 
solution.  There  is  a  very  annoying  form  of  irritation  of  a  partially 
prolapsed  urethral  mucous  membrane  in  middle-aged  and  elderly 
women  which  is  an  expression  of  gout  or  rheumatism  ;  which 
yields  promptly  to  the  appropriate  remedies  for  those  systemic 
conditions,  but  resists  indefinitely  local  treatment. 

If  the  prolapsus  is  very  marked,  or  if  palliative  treatment  fails, 
the  projecting  mucous  membrane  should  be  excised  by  a  circular 
incision  and  the  raw  surface  covered  by  interrupted  catgut  sutures 


Tuberculosis  of  the  Urethra  565 

which  unite  the  nuicous  membrane  of  the  urethra  with  that  of  tlie 
meatus. 

Foreign  bodies  in  the  urethra  are  the  same  as  those  in  the 
bladder  and  are  inserted  there  in  the  same  way,  usually  being  intro- 
duced in  attempts  at  masturbation.  Vesical  calculi  may  be  lodged 
in  the  urethra. 

The  symptom  is  dysuria  or  complete  retention  of  urine. 

The  diagnosis  is  made  by  the  urethral  sound,  the  urethroscope, 
and  palpation  of  the  canal  through  the  vagina. 

The  treatment  is  extraction  of  the  foreign  body  by  a  narrow- 
bladed  forceps,  or  b}-  snaring  it  with  a  wire  loop,  the  forefinger 
pressing  it  downward  through  the  urethrovaginal  septum.  If  its 
extraction  by  the  meatus  is  impossible,  an  incision  may  be  made 
over  it  in  the  urethrovaginal  septum,  \\hich  should  be  united  again 
by  sutures. 

Urethral  fistula  is  very  rare.  It  follows  pressure-necrosis  of 
the  urethrovaginal  septum  after  labor.  It  is  recognized  by  in- 
spection and  by  the  use  of  a  probe.  There  is  no  incontinence  of 
urine  unless  the  neck  of  the  bladder  is  involved.  The  fistula  is 
closed  by  the  same  operatixe  procedures  demanded  by  vesicovag- 
inal fistuls. 

Skene  calls  attention  to  an  incomplete  urethral  fistula  in  which 
a  blind  sinus  leads  from  the  urethral  canal  into  the  tissues  of  the 
urethrovaginal  septum.  There  is  persistent  suppuration  of  the 
sinus  tract,  with  a  purulent  discharge  from  the  meatus,  irritation 
of  the  urethra,  and  frequent  painful  urination.  By  palpation  an 
inflammatory  infiltration  of  the  urethral  wall  is  felt ;  by  endoscopy 
the  orifice  of  the  sinus  is  seen  in  the  urethra,  and  by  inserting  a 
small  probe  with  a  curved  point,  the  direction  and  extent  of  the 
fistulous  tract  can  be  determined. 

The  treatment  is  an  incision  into  the  lowest  portion  of  the 
sinus  from  the  vagina,  making  the  fistula  complete.  By  using  a 
catheter  to  prevent  the  irritation  of  the  urethra  by  micturition  and 
b\"  irrigating  the  urethra  with  boracic  acid  solution,  the  fistula 
usually  closes  spontaneously.  If  it  does  not,  it  can  be  closed  by 
a  plastic  operation. 

Tuberculosis  of  the  urethra  is  secondar}'  to  tuberculosis  of 
the  rest  of  the  urinary  tract.  The  tubercular  inflammation  is 
usually  centered  in  Skene's  glands,  which  are  distended  with 
caseous  material  and  are  ulcerated  around  their  orifices.  The  local 
inflammation  can  be  cured  by  the  insertion  of  an  electrocautery 
point  into  the  follicles  and  their  destruction.  If  there  is  a  more 
extensive  involvement  of  the  urethra  the  local  treatment  might  be 
the  application  of  the  Rontgen  and  the  Finsen  ray  or  excision  of 
the  diseased  area  ;  but  the   disease  of  the  bladder  and   kidneys 


566  Diseases  of  the  Urinary  Tract 

accompanying  the  tubercular  urethritis  makes  the  latter  of  subor- 
dinate importance. 

Floating  Kidney. — All  the  diseases  of  the  kidney  are  com- 
mon to  both  sexes,  but  a  dislocated  and  mobile  kidney  deserves 
a  place  among  the  diseases  of  women.  It  is  rarely  found  in  men. 
In  Kdebohls'  186  operative  cases  only  3  were  in  men.  Legry's, 
Lanceraux's,  Landau's,  Skorezewsky's,  and  Morris'  statistics 
show  that  women  are  five  to  ten  times  more  frequently  affected 
than  men,  and  that  the  latter  rarely  require  operative  treatment.  ^ 
The  investigation  of  the  position  and  mobility  of  the  kidneys  is  a 
part  of  every  gynecological  examination.  About  a  fifth  of  all 
women  examined  exhibit  an  abnormally  low  and  mobile  right 
kidney,  with  its  lower  pole  often  at  or  below  the  level  of  the 
umbilicus.  It  is  rare  to  find  both  kidneys  abnormally  mobile 
and  low  in  situation  in  the  erect  or  sitting  posture.  If  both  are 
displaced,  the  right  is  almost  always  the  lower  and  more  mobile 
of  the  two.  Only  a  small  proportion  of  women  with  a  displaced 
and  mobile  kidney  exhibit  symptoms  traceable  to  the  renal  dis- 
placement and  require  treatment. 

The  causes  of  floating  kidney  are  not  clearly  understood. 
The  pouch  in  which  the  kidney  rests  is  shorter  and  broader 
below  in  the  female  ;  this  peculiarity  is  most  marked  on  the  right 
side.  Other  reasons  why  the  right  kidney  is  displaced  more  than 
thirteen  times  oftener  than  the  left  are  found  in  the  weight  of  the 
liver ;  the  greater  length  of  the  renal  vessels  on  the  right  side  ; 
the  loose  connection  between  the  ascending  colon  and  the  right 
kidney  ;  an  aponeurotic  layer  between  the  peritoneum  and  the 
anterior  surface  of  the  left  kidney,  absent  on  the  right  side  ;  and 
the  connection  of  the  left  suprarenal  capsular  vein  with  the  renal 
vein.  These  conditions,  however,  do  not  give  the  left  kidney 
immunity  from  displacement  and  mobility.  Both  kidneys  are  dis- 
placed and  mobile  in  5  per  cent,  of  the  cases  of  floating  kidney. 
Lifting  heavy  weights  ;  traumatism,  as  a  kick  or  blow  in  the 
lumbar  region,  a  violent  jolt  or  jar  ;  rapidly  repeated  pregnan- 
cies ;  evacuation  of  fluids  from  the  abdomen  ;  emaciation,  espe- 
cially with  absorption  of  the  fatty  capsule  of  the  kidney  ;  diasta- 
sis of  the  abdominal  recti  muscles  ;  pendulous  abdomen  ;  gas- 
troptosis  and  enteroptosis,  usually  from  premature  exertion  on 
the  feet  after  childbirth  ;  the  recurrent  hyperemia  of  the  men- 
strual periods  ;  relaxation  of  all  the  tissues  in  an  anemic,  weak 
woman  ;  increased  weight  and  size  of  the  kidney  from  any 
cause  ;  tight  lacing  ;  high-heeled  shoes  ;  and  violent  or  repeated 
coughing,  sneezing,  and  hiccoughing  have  all  been  considered 
as  the  causes  of  floating  kidney. 

1  Morris,  "  Surgical  Diseases  of  the  Kidney  and  Ureter." 


Symptoms  of  Floating  Kidney  567 

Of  all  these  causes,  absorption  of  the  fatt)-  capsule  of  the 
kidney  in  emaciated  women  is  regarded  as  the  commonest,  but 
perhaps  it  is  because  the  diagnosis  of  floating  kidney  is  so 
much  more  easily  made  in  such  women.  I  have  found  very 
mobile  kidneys  in  fat  women  by  intra-abdominal  palpation  during 
an  abdominal  section,  that  could  not  be  diagnosticated  by  the 
ordinary  methods  of  examination. 

The  symptoms  of  floating  kidney  are  subjective  and  ob- 
jective. 

Tlic  subjective  symptoms  are  a  dull  aching  pain  and  dragging 
sensation  in  the  back  and  side  or  between  the  shoulders  ;  crises 
of  pain  suggesting  renal  colic ;  neuralgic  pains  of  the  great 
nerve-trunks  on  the  affected  side ;  a  sensation  of  something 
moving  in  the  abdomen,  somewhat  like  fetal  movements  ;  the 
appreciation  by  the  patient  herself  of  a  "lump"  in  the  abdomen 
which  appears  and  disappears ;  \'aried  disturbances  of  the  gastro- 
intestinal tract,  such  as  vomiting  preceded  by  epigastric  pain, 
sudden  gaseous  distention  of  the  abdomen;  obstinate  constipa- 
tion varied  perhaps  by  diarrhea,  \'iolent  attacks  of  colic,  with 
nausea,  vomiting,  flatulence,  and  occasionally  signs  of  collapse 
(Dietl's  crises)  ;  abnormalities  of  urinary  secretion,  as  polyuria, 
frequent  micturition,  pyuria  and  hematuria  ;  and  symptoms  of 
associated  irritation  of  the  gall-bladder  or  of  the  appendix.  The 
patient  often  complains  of  inability  to  stand  or  sit  erect ;  she  is 
disposed  to  stoop.  She  finds  herself  instinctively  raising  the 
right  shoulder  or  habitually  keeping  it  higher  than  the  left  if  the 
right  kidney  alone  is  displaced.  The  symptoms  usually  disap- 
pear in  the  recumbent  posture  and  are  excited  or  aggravated  by 
standing  or  walking. 

A  large  proportion  of  women  w^ith  mobile  and  displaced 
kidneys  have  no  s}'mptoms  at  all  traceable  to  a  floating  kidney. 
The  percentage  of  cases  requiring  operation  or  other  treatment  is 
ver^^  small  indeed.^ 

TJic  objective  symptoms  are  elicited  by  palpation  of  the  kidne}^ 
and  the  abdomen,  and  b}'  abdominal  percussion. 

The  palpation  of  the  kidney  has  already  been  described. 
The  best  position  of  the  patient  for  it  is  the  erect  sitting  posture, 
with  the  back,  head,  and  feet  supported,  the  arms  hanging  limp 
alongside  of  her,  with  quiet,  regular  mouth-breathing.  Other 
postures  for  the  examination  are  the  supine,  with  the  legs  drawn 
up  and  the  feet  supported  ;  the  knee-elbow  ;  the  erect  posture, 

1  For  example,  in  my  hospital  services  and  office  practice  during  the  last  year  I 
examined  or  had  examined  for  me  considerably  more  than  a  thousand  patients.  All 
these  women  w^re  routinely  examined  for  the  position  of  the  kidney.  Out  of  this 
number  only  5,  in  my  judgment,  required  nephrorrhaphy,  although  something  like  200 
had  a  demonstrably  displaced  and  mobile  kidney. 


568  Diseases  of  the  Urinary  Tract 

with  the  trunk  flexed  and  the  arms  supported  on  a  chair  or  the 
shoulders  leaning  against  a  support ;  the  lateral  and  the  Sims'  or 
semi-prone  position.  The  bimanual  grasp  of  the  kidney  has 
been  described  (p.  535). 

A  floating  kidney  sometimes  behaves  most  peculiarly  in  its 
mobility  and  displacement.  In  the  course  of  an  examination  it 
ma}^  be  replaced  and  can  not  again  be  dislodged.  It  may  be 
markedly  displaced  and  mobile  one  day,  but  remain  in  perfectly 
normal  position  without  mobility  for  days  together.  Repeated 
examinations,  therefore,  are  sometimes  required  to  recognize  a 
floating  kidne}%  and  the  patient  should  have  been  moving  about 
actively  on  her  feet,  if  possible,  before  the  examination  is  made. 

In  the  average  case  the  lower  pole  of  the  right  kidney  is  on 
a  level  with  the  umbilicus;  by  compressing  this  pole  between  the 
fingers  of  the  two  hands  the  kidney  may  be  made  to  slip  up  under 
the  floating  ribs,  returning  again,  as  a  rule,  to  its  low  position 
when  the  pressure  on  the  flank  is  removed.  It  is  not  uncommon 
to  find  the  lower  pole  two  or  three  inches  below  the  umbilicus 
and  the  whole  length  of  the  kidney  palpable  below  the  ribs.  In 
exceptional  cases  it  is  possible  to  push  the  kidney  into  the  pelvis, 
up  under  the  ribs  and  across  the  median  hne  to  the  other  side  of  the 
abdomen.  The  physician  or  patient  may  grasp  the  kidney  through 
her  abdominal  walls  and  move  it  about  at  will.  The  long  axis 
of  the  kidney  may  remain  longitudinal,  may  be  oblique,  or  even 
transver.se. 

It  is  the  mobile  and  not  the  displaced  kidney  that  causes 
symptoms.  A  kidney  adherent  to  the  pelvic  brim  is  usually  ac- 
cidentally discovered  as  an  obstacle  in  labor. 

Percussion  yields  a  muffled  tympanitic  note  over  the  dis- 
placed kidney  and  there  is  some  resonance  over  the  vacated 
kidney  pouch  from  behind,  which  disappears  when  the  kidney  is 
pushed  back  into  place.  Hydronephrosis  is  a  frequent  accom- 
paniment of  floating  kidney,  which  may  remain  permanently  en- 
larged or  be  subject  to  acute  attacks  of  distention  with  remissions 
in  which  the  dilatation  apparently  disappears.  In  the  attacks  the 
symptoms  may  be  serious ;  intense  pain,  rapid  pulse,  and  high 
temperature  may  be  observed.  The  hydronephrosis  is  due  to  a 
kink  in  the  ureter. 

Treatment. — As  already  stated,  many  cases  require  no  treat- 
ment at  all.  If  any  of  the  symptoms  detailed  above  are  clearly 
traceable  to  a  floating  kidney;  if  appendicitis, ^    or  other  disease 

^  Edebohls  is  a  firm  believer  in  the  association  of  appendicitis  with  floating 
kidney.  It  is  probable,  however,  that  the  discomfort  of  appendiceal  irritation  leads  a 
patient  to  seek  medical  advice.  In  at  least  a  fifth  of  such  cases  the  kidney  is  mobile. 
An  enthusiast  in  the  surgical  treatment  of  floating  kidney  could  easily  see  in  such  an 
accidental  association  an  additional  indication  for  nephrorrhaphy. 


Treatment  of  Floating-   Kidney  569 

of  the  alimentary  tract  can  be  excluded;  if  the  pelvic  organs  are 
normal  or  if  with  other  disease  in  the  abdomen  or  pelvis  it  is 
possible  to  differentiate  the  s\'mptoms  and  physical  signs  of  float- 
ing kidney  from  associated  affections,  treatment  is  indicated. 

The  treatment  is  palliative  and  radical,  or  operative.  There 
are  two  kinds  of  palliative  treatment.  One  is  to  subject  the 
patient  to  a  rest  cure,  with  forced  feeding,  electricit}',  and 
massage.  A  long  retention  in  the  recumbent  posture  with  in- 
creased fat  deposits  in  which  the  fatty  capsule  shares  ;  the  in- 
creased tonicity  of  the  abdominal  walls  secured  by  electricity  and 
massage,  1  have  not  infrequently  cured  a  floating  kidney  perma- 
nently. The  second  method  of  palliative  treatment  is  the  ad- 
justment of  a  belt  or  corset,  reinforced  sometimes  by  a  pad,  to 
increase  intra-abdominal  pressure  in  a  direction  from  below 
upward.  The  simplest  and  often  the  best  support  for  a  floating 
kidney  is  the  straight-front  corset,  put  on  in  the  recumbent  posture 
and  fastened  from  below  upward,  while  a  hand  is  inserted  under 
it  to  lift  the  abdominal  wall  upward.  It  is  sometimes  necessary 
to  sew  a  wedge-shaped  pad  with  the  base  below  to  the  inner  side 
of  the  corset  and  on  the  affected  side,  not  with  the  idea  of 
directly  pressing  upon  and  affording  the  kidne}'  support,  but  to 
increase  intra-abdominal  pressure  and  thus  indirectly  to  contrib- 
ute to  the  support  of  the  kidney.  Occasionally  a  pneumatic  pad 
is  more  comfortable  than  a  solid  one.  It  is  sometimes  necessary 
to  adjust  the  support  with  the  patient  in  the  Trendelenburg 
posture  over  the  back  of  a  chair,  laid  face  downward  on  the  bed. 
A  woven  abdominal  binder  with  a  pad  on  its  under  side  may  be 
more  comfortable  and  more  effectual  than  the  corset. 

If  the  palliative  treatment  fails  to  relieve  the  patient  ;  if  her 
symptoms  are  so  troublesome  or  painful  that  she  demands  relief; 
if  she  is  not  willing  to  endure  or  can  not  afford  the  partial  or 
complete  invalidism  that  a  floating  kidney  sometimes  entails  ;  if  the 
nervous  system  threatens  to  break  down  under  the  strain  of  con- 
tinued suffering  or  of  acute  crises  of  pain,  the  radical  or  opera- 
tive treatment  should  be  advised.  There  are  two  operations  to 
be  considered  for  floating  kidney — nephrorrhaphy  and  the  junc- 
tion of  the  recti  muscle-sheaths  for  diastasis. 

XcpJirorrliaphy. — Many  methods  have  been  proposed  and 
adopted  for  fixing  a  floating  kidney  since  the  first  operation  by 
Hahn  in  1881.  Sutures  through  the  kidney  substance  and  the 
back  muscles  ;  the  utilization  of  the  last  rib  as  a  fixed  point ; 
gauze  packing  or  rubber  tubing  around  the  kidney,  emerging 
from  the  lumbar  wound,  to  produce  adhesions,  all  have  had  their 

^  Special  methods  of  massage  in  the  renal  region  (vibratory  movement)  are 
a  useless  waste  of  time. 


570 


Diseases  of  the  Urinary  Tract 


advocates.  The  technic  of  Edebohls  described  in  1901  ^  has 
proved  in  the  author's  experience  so  much  more  satisfactory  than 
any  other  that  in  his  judgment  it  is  the  only  one  meriting  descrip- 
tion. Any  one  who  contrasts  in  actual  practice  the  Edebohls 
operation  with  the  others  will  be  loath  to  return  to  the  older  meth- 
ods.     The  steps  of  the  operation  are  thus  described  by  its  author  : 

"  Place  the  patient  prone  upon  the  table  with  Edebohls' 
kidney  air-cushion  underlying  and  supporting  the  abdomen  (Fig. 
480). 

"  Make  a  straight  incision  along  the  outer  border  of  the 
erector  spinae  from  lower  border  of  last  rib  to  crest  of  ilium. 
Should  the  space  between  the  rib  and  ilium  be  unusually  narrow, 
carry  the  incision  a  little  more  obliquely,  so  that  its  lower  end 


Fig.  480. — Edebohls'  kidney  air-cushion,  with  patient  in  position  for  operation. 

will  reach  the  ilium  shghtly  to  the  outer  side  of  the  attachment 
of  the  erector  spinae. 

"  Bluntly  separate  the  fibers  of  the  latissimus  dorsi  from  each 
other  just  over  the  outer  border  of  the  erector  spinae,  without 
opening  the  sheath  of  the  latter.  Split  the  transversalis  fascia 
and  expose  the  perirenal  fat.  Draw  the  iliohypogastric  nerve 
to  one  side  or  other  out  of  the  way  of  injury.  If  this  can 
not  be  done  and  the  nerve  must  be  divided,  reunite  the  severed 
ends  with  catgut  after  anchoring  the  kidney  and  before  closing 
the  wound. 

"  Open  the  sheath  of  the  quadratus  lumborum  from  rib  to 
iUum  along  the  anterior  aspect  of  its  lateral  border.      The  retrac- 

1  Before  the  Medical  Society  of  the  State  of  New  York,  October  15,  1901. 


Treatment  of  Floating  Kidney  571 

tion  of  the  cut  edges  of  the  slieath  will  expose  a  large  area  of 
raw  muscle. 

"  Free  the  kidney  as  far  as  necessar}-  by  blunt  dissection 
with  the  fingers,  aided  by  an  occasional  clij)  of  the  scissors. 

"  Deliver  the  kidney  with  its  fatty  capsule  through  the 
wound  onto  the  back.  Traction  upon  the  fatty  capsule,  aided 
by  rolling  the  patient  upward  or  downward,  as  may  be  neces- 
sary, on  the  air-cushion,  facilitates  this  part  of  the  procedure. 
The  upper  pole  of  the  kidney  generally,  though  not  always, 
emerges  first,  the  rest  of  the  organ  following.  Should  the 
opening  through  the  walls  of  the  abdomen  prove  too  small 
for  delivery  of  the  kidney,  enlarge  it  by  nicking  the  outer  fibers 
of  the  quadratus  near  its  iliac  insertion. 

"  Dissect  off  and  remove  the  whole  of  the  fatty  capsule, 
exposing  the  capsule  proper  throughout  its  entire  extent. 
Explore  by  palpation  the  kidney,  its  pelvis,  and  the  upper  end 
of  the  ureter.  Should  anything  be  found  to  indicate  punc- 
ture or  incision,  this  is  the  proper  time  to  perform  either. 

"  Nick  the  capsule  proper  of  the  kidney  near  the  middle  of 
the  convex  border  just  sufficiently  to  admit  the  tip  of  a  grooved 
director.  Pass  the  director  through  the  opening  and  on  beneath 
the  capsule  proper,  between  the  latter  and  the  kidney,  and  upon 
it  divide  the  capsule  proper  along  the  entire  length  of  the  convex 
border  of  the  kidney  to  half-way  around  both  the  upper  and 
lower  poles  of  the  organ.  Separate  the  capsule  proper  by  blunt 
dissection  on  either  side  of  the  incision  from  the  kidney  substance, 
and  reflect  it  forward  and  backward  toward  the  renal  pelvis  to 
about  midway  between  the  external  and  internal  borders  of  the 
kidney.  This  will  leave  denuded  one-half  of  the  kidney,  more  or 
less,  the  detached  portiori  of  the  capsule  proper  being  continuous 
with  the  still  attached  portion  and  turned  back  upon  it  like  the 
lapel  of  a  coat.  Resect  a  portion  of  the  detached  capsule  proper, 
if  too  redundant. 

"  Pass  four  suspension  or  fixation  sutures  of  forty-day  cat- 
gut^ through  both  the  reflected  and  the  still  attached  capsule 
proper,  close  to  their  line  of  junction.  Two  sutures  are  placed 
on  the  anterior  face  of  the  kidney,  one  at  the  middle  of  the  upper 
and  one  at  the  middle  of  the  lower  half  of  the  organ.  The  two 
other  sutures  are  placed  at  corresponding  points  of  the  posterior 
surface  of  the  kidney.  Each  suture  runs  parallel  to  the  long 
axis  of  the  kidney,  and  is  passed  through  the  reflected  capsule 
close  to  the  line  of  reflection,  then  through  the  underlying  at- 
tached capsule,  and  along  beneath  the  latter  between  the  capsule 
and  the   kidney  substance,  for  a  distance  of  two  or  three  centi- 

1  The  author  uses  formahn  gut  of  three  or  four  weeks'  durability. 


572 


Diseases  of  the  Urinary  Tract 


meters,  when  it  again  emerges  through  the  attached  and  reflected 
layers  of  the  capsule  (Fig.  481).  Use  a  Hagedorn  needle,  with 
the  broad  surface  running  flatwise  between  the  capsule  proper 
and  the  kidney  substance,  to  avoid  penetration  of  the  latter. 

"  Pass  the  kidney  with  the  eight  free  suture  ends  hanging 
from  the  capsule  proper  back  into  the  body.  Pass  each  suture 
end  in  succession  through  the  abdominal  parietes  from  within 
outward,  four  to  the  inner  and  four  to  the  outer  side  of  the  in- 
cision, each  suture  piercing  the  tissues  at  a  distance  from  its  fellow 
of  the  opposite  surface  equal  to  the  anteroposterior  thickness  of 
the  kidney.  The  sutures  to  the  inner  side  of  the  incision  will 
pierce  the   retracted  sheath  of  the  quadratus  near  its   edge,  the 


Fig.  481. — Showing  two  of  the  four  suspension  sutures  passed  through  reflected 
and  attached  layers  of  capsule  proper,  without  penetration  of  kidney  substance.  The 
two  companion  sutures,  passed  on  the  opposite  face  of  the  kidney,  are  not  shown 
(Edebohls). 


quadratus  itself,  and  the  erector  spin?e;  the  outer  sutures  will 
ti-averse  the  transversalis  fascia  and  the  latissimus  dorsi.  All 
of  the  sutures  will  emerge  upon  the  surface  of  the  latissimus 
dorsi  at  distances  from  each  other  equal  to  those  at  which  they 
leave  the  capsule  proper,  the  highest  suture  ends  emerging 
immediately  beneath  the  twelfth  rib  (Fig.  482).  Leave  the 
sutures  untied  for  the  present. 

"  Close  the  wound  of  the  muscles  and  fascia  by  from  four  to 
six  interrupted  sutures  of  forty-day  catgut,  passed  in  such  a  man- 
ner as  to  turn  the  raw  surface  of  the  quadratus  toward  the  kidney. 
This  is  effected  by  suturing  the  latissimus  dorsi  and  the  lumbar 
fascia  forming  the  outer  lips  of  the  wound  to  the  latissimus  dorsi, 


Treatment  of  Floating-  Kidney 


573 


the  sheath  of  the  erector  spiiiae  and  the  outer  hp  of  the  open  slieath 
of  the  quadratus  at  the  inner  margin  of  the  incision. 

"  Gentlv  draw  taut  the  eight  ends  of  the  fixation  sutures  to 


Fig.  482. — The  kidney  has  been  replaced  and  the  ends  of  the  suspension  sutures 
have  been  brought  through  the  abdominal  wall,  emerging  on  the  outer  surface  of  the 
latissimus  dorsi.  The  fibers  of  the  muscle  have  been  separated  from  each  other,  not 
cut,  in  making  the  incision  (Edebohls). 


rig.  483. — Suspension  sutures  and  sutures  closing  deep  parts  of  wound  tied  (Ede- 
bohls). 


take  in  slack  between  the  internal  surface  of  the  abdominal  pa- 
rietes  and  the  capsule  proper,  so  as  to  bring  the  denuded  surface 


574 


Diseases  of  the  Urinary  Tract 


of  the  kidney  into  contact  with  the  raw  surface  of  the  quadratus. 
Tie  the  two  ends  of  each  of  the  four  suspension  sutures  to  each 
other  (Fig.  483).  Bury  the  suspension  and  muscle  sutures  by 
closing  the  skin  over  them  with  the  intracuticular  suture. 

"  The  completed  operation   will    leave  the  denuded  convex 


Fig.  484. — Effects  of  the  completed  operation,  showing  broad  apposition  of  the 
denuded  kidney  and  rawed  quadratus.  The  track  of  the  suspension  sutures  is  also 
shown  (Edebohls). 


surface  of  the  outer  half  of  the  kidney  in  snug  contact  with  the 
raw  quadratus  lumborum  throughout  the  entire  length  of  the 
latter  from  rib  to  ilium  (Fig.  484),  the  upper  pole  of  the  kidney 
projecting  slightly  upward  beneath  the  ribs  and  the  lower  pole 
reaching  to  an  equal  extent  below  the  level  of  the  iliac  crest. 

"  Apply  the  dressings  across  the  entire  width  of  the  back, 
smoothly  and  evenly,  remembering  that  the  patient  is  to  He  upon 
them  for  a  week  before  changing." 

TJie  Support  of  a  Floating  Kidney  by  the  Operative  Treatment 
of  Diastasis  of  the  Recti  Muscles. — If  a  floating  kidney  follows 
childbirth  and  is  associated  with  diastasis  of  the  recti  muscles,  pen- 
dulous abdomen,  enteroptosis,  and  gastroptosis,  nephrorrhaphy 
alone  will  not  make  the  patient  comfortable,  and  may  not  be 
necessary.  If  an  abdominal  binder,  electricity,  massage,  and 
Swedish  exercises  fail  to  restore  tone  to  the  relaxed  abdominal 
walls  and  to  correct  the  splanchnoptosis,  uniting  the  sheaths  of 
the  recti  muscles  as  proposed  by  J.  C.  Webster  often  gives  the 
kidneys  as  well  as  other  abdominal   organs   such   good  support 


Treatment  of  Floating  Kidney 


575 


and  the  patient  such  perfect  symptomatic  relief  that  nothing- 
further  is  required.  This  operation,  therefore,  should  precede  or 
replace  nephrorrhaphy  in  suitable  cases.  The  author's  technic 
is  as  follows  :  An  incision  is  made  from  midway  between  the 
umbilicus  and  the  ensiform  cartilage  to  the  symphysis.  The  skin 
and  subcutaneous  fat  are  dissected  off  the  fascia  until  the  sheaths 
of  both  recti  muscles  are  exposed.  The  sheath  of  one  muscle 
at  its  inner  edge  is  nicked  with  a  knife  until  the  muscle  itself  comes 


Fig.  485. — After  Mayolle,  from  a  patient  of  Buret,  who  died  of  pulmonary  tuber- 
culosis six  months  after  right  nephropexy.  Kidney  turned  outward  to  show  connective- 
tissue  band,  six  centimeters  long  by  two  centimeters  thick,  resulting  from  operation 
and  attaching  kidney  to  posterior  abdominal  wall  (Edebohls). 


into  view  ;  the  sheath  is  slit  with  scissors  the  whole  length  of  the 
wound  ;  the  other  sheath  is  similarly  treated.  The  recti  muscles 
are  freed  from  their  underlying  attachments  by  a  blunt  dissec- 
tion. Four  to  six  mattress  sutures  of  formalin  gut  (No.  3)  are 
passed  through  the  outer  edges  of  the  muscle-sheaths,  skipping 


5/6  Diseases  of  the  Urinary  Tract 

the  tissues  between.  Silkworm-gut  sutures  are  passed  between 
the  mattress  sutures  taking  in  the  skin,  the  subcutaneous  fat,  and 
the  outer  edges  of  the  muscle-sheaths.  The  mattress  sutures 
are  tied  in  a  triple  knot.  A  continuous  catgut  suture  (No.  3, 
formalin)  unites  the  whole  length  of  the  outer  edges  of  the 
muscle-sheaths.  The  interrupted  silkworm-gut  sutures  are  tied. 
The  intervening  skin  surfaces  are  joined  either  by  a  continuous 
catgut  suture  or  Michel's  clamps.  The  silkworm-gut  sutures 
remain  for  ten  to  twelve  days,  when  they  are  removed. 

Ncp]iro-2ir€tercctoi]iy  in  Women. — Descriptions  of  nephrectomy 
are  out  of  place  in  a  treatise  on  diseases  peculiar  to  women.  In 
operations  for  tuberculous  kidney,  however,  or  for  pyonephrosis 
and  infected  sacculated  ureter  from  any  cause  with  which  the 
gynecologist  not  infrequently  has  to  deal,  the  question  of  remov- 
ing the  whole  or  a  great  part  of  the  ureter  arises. 

Teclinic  of  Ureterectomy  in  Women. — The  ureter  may  be  re- 
moved with  the  kidney  by  an  extraperitoneal  or  a  transperitoneal 
operation.  In  the  former  the  incision  may  be  lumbo-ilio-inguinal 
or  lumbo-ilio-inguinal  and  vaginal.  In  the  latter  the  incision  is 
made  through  the  semilunar  line,  the  peritoneum  over  the  ureter 
is  buttonholed  so  that  successive  lengths  may  be  pulled  out,  the 
wounds  in  the  peritoneum  being  subsequently  closed  by  suture. 

If  the  combined  lumbar  and  vaginal  incision  is  selected,  the 
vagina  may  be  opened  last  to  secure  and  remove  the  stump  of 
the  ureter  left  after  its  amputation  above,  or  the  operation  may 
be  begun  by  a  vaginal  section,  detachment  of  the  ureter  from 
the  bladder,  and  its  extraction  from  above  through  the  lumbar 
and  inguinal  wounds.  It  is  not  absolutely  necessary  to  tie  the 
stump  of  the  ureter,  as  regurgitation  of  urine  is  rare ;  but  the 
majority  of  operators  must  feel,  as  the  author  has,  that  it  is  safer 
to  do  so.  Bovee  ^  has  collected  the  records  of  41  operations. 
The  author  has  done  one  not  included  in  Bovee's  statistics,  a  com- 
plete ureterectomy  by  a  lumbo-ilio-inguinal  incision  for  tubercu- 
losis of  the  kidney,  though  it  appeared  by  an  examination  of  the 
specimen  after  the  removal  that  the  ureterectomy  was  not  really 
neces.sary.  The  patient  recovered  and  gained  twenty  pounds  in 
the  six  weeks  following  operation. 

1  "  Nephro-ureterectomy,"  "  N.  Y.  Med.  Jour.,"  Jan.  25,  1902. 


PART  XII. 

THE  DETAILED  TECHNIC  OF  GYNECIC  SURGERY. 

The  Operating  Room. — The  requirements  for  a  modern  oper- 
ating room  differ  as  the  room  is  designed  simply  for  operative 
work  or  for  the  instruction  of  students  in  addition.  In  the 
former  case  the  following  considerations  should  be  taken  into 
account :  The  floor  and  walls  are  made  of  non-absorbable,  easily 
cleansed  material.      For  the  former,  white  hexagonal  tiles,  ^  and 


Fig.   486. — Operating  room  in  the  Howard  Hospital,   of  Philadelphia.      Operating 
table  and  room  arranged  for  a  plastic  operation. 


for  the  latter,  glass  wainscoting,  are  the  best.  The  room  should 
be  heated  to  go°  F.  There  should  be  no  draughts  of  hot  air  to 
blow  dust  about.  The  best  heating  apparatus  is  a  coil  of  heavy 
nickel-plated  tubes   for  hot   water  or  steam.      The  floor  should 

1  x\  glass  floor  was  first  tried  in  the  operating  room  of  the  Howard  Hospital.  It 
was  in  many  ways  ideal,  but  the  expense  of  repairing  the  heavy  glass  plates  that 
were  occasionally  broken  proved  too  great. 

37  577 


578       The  Detailed  Technic  of  Gynecic  Surgery- 
have  a  vent  for  the  water  with  which  it  is  flushed,  but  this  vent 
should  not  communicate  with  the  sewer.      In  the  Howard  Hos- 
pital  it   leads  into   a   pipe  which   stops  three  feet  short  of  the 
ground,  the  water  falling  into  a  covered  gutter. 

The  light  is  furnished  by  a  skylight  and  windows,  so  that  it 
is  both  vertical  and  horizontal.  The  light  should  be  from  the 
north.  The  cut  in  the  roof  and  wall  should  be  continuous, 
the  glass  in  the  wall  and  the  roof  having  no  intervening  struc- 
tural work  except  light  iron  frames.  Small  hot-water  or  steam 
pipes  should  run  along  the  iron  frames  of  the  window  and  sky- 
light, to  prevent  chilling  the  air  by  the  large  glass  surface,  the 


Fig.  487. — Hand  disinfection  trough  and  water  sterilizers  (Howard  Hospital). 


creation  of  draughts,  and  the  "sweating"  of  the  glass.  A  cluster 
of  eight  or  ten  incandescent  electric  lights  should  be  suspended 
abpve  the  operating  table,  and  there  should  be  one  or  more  plugs 
in  the  wall  for  the  attachment  of  hand  and  head  lights. 

The  sterilizing  outfit  should  comprise  two  autoclave  sterilizers, 
a  water  sterilizer,  an  instrument  sterilizer,  and  an  implement 
sterilizer  for  basins,  pitchers,  etc.  The  sterilizers  may  be  in  an 
adjoining  room,  but  it  is  more  convenient  to  have  them  in  the 
operating  room  itself,  if  possible,  in  recesses  out  of  the  way  and 
yet  accessible.  A  trough  should  be  provided,  long  enough  for 
three  men  to  stand  in  front  of,  in  which  sterile  basins  are  placed 
for  the  hand  cleansing.      This  trough  should  have  hot-  and  cold- 


The   Operating  Room 


579 


water  spigots  with   pedal  stops,  although  tap  water  is  not  used 
for  the  hand  cleansing. 


The  ordinary  furniture  of  an  operating  room — glass  cases  for 
dressings,  glass-top  tables,  basin  stands  and  basins,  enameled 
iron    stools,    apparatus   for   normal   salt   injection,    materials  for 


580       The  Detailed  Technic  of  Gynecic  Surgery 

hypodermic  stimulation — is  naturaUy  required.  The  instrument 
cases  and  instruments  should  be  kept  in  an  adjoining  room,  as 
they  may  be  rusted  by  the  moist  hot  air  of  the  operating-  room. 

A  chnical  amphitheater  for  demonstrating  pelvic  and  ab- 
dominal surgery  to  medical  students  should  have  ample  floor 
space,  so  that  the  operator  and  his  assistants  shall  not  be  un- 
comfortably crowded,  and  to  provide  room  for  two  or  more  oper- 


Fig.  489. — Water  sterilizers  ;   instrument  and  implement  sterilizers  in  an  alcove  (Uni- 
versity Hospital). 


ating  tables  in  use  at  once.  In  the  limited  time  at  the  disposal 
of  the  teacher,  closing  the  abdominal  wound  should  be  relegated 
to  competent  assistants,  so  that  two  or  three  abdominal  or  pelvic 
operations  may  be  shown  in  the  hour. 

The  .sterilizing  plant  should  be  in  view  of  the  students,  and 
they  should  also  witness  the  hand  cleansing  process,  day  after  day, 
so  that  it  may  be  thoroughly  familiar  to  them.     The   operator 


The  Operating  Room 


581 


and  his  assistants  should  don  their  head  coverings,  gowns,  and 
gloves  before  the  students.  In  short,  the  whole  process  of  pre- 
paring for  an  operation  should  be  regularly  exhibited  until  at  the 
end  of  a  session  each  step  is  so  familiar  that  it  could  not  well  be 
forgotten. 

In  a  private  house  the  room  selected  for  an  operation  should 
be  near  that  in  which  the  patient  lies  in  bed.      For  an  abdominal 


Fig.  490. — Two  autoclave  steam  sterilizers  in  an  alcove,  but  in  view  of  the  students 
(University  Hospital). 


or  vaginal  section,  shortening  of  the  round  ligaments  and  sus- 
pending the  kidney,  the  furniture,  carpets,  and  hangings  should 
be  removed. 

The  floor  should  be  scrubbed  with  soap  and  water,  and  then 
mopped  with  a  sublimate  solution,  shortly  before  the  operation, 
so  that  it  shall  be  damp  and  no  dust  will  be  raised  by  walking 
over  it.      For  a  plastic  operation  it  suffices  to  tack  over  the  carpet 


582       The  Detailed  Technic  of  Gynecic  Surgery 

a  sheet  which  has  been  wrung  out  in  a  subhmate  solution,  but  is 
left  moist. 

The  basins  and  pitchers  are  boiled  in  a  large  clothes  boiler. 


Fig.  491. — The  Rochester  sterilizer  for  dressings,  etc. 


Fig.  492. — The  author's  operating  table,  of  enameled  iron  with  inflated  air-cushion. 

The  dressings  and  ligature  material  are  sterilized  either  in  the  cage 
of  a  hospital  autoclave,  which  is  transported  to  the  house  wrapped 
in  double  sheets,   or  in  the   house  itself  in  a  Rochester  steam 


The  Operating  Room 


583 


sterilizer.  1      A  large  quantity  of  boiling  water  is  on  hand  at  the 
hour  of  operation,  and  boiled  water  is  provided  in  pitchers  with 


Fig.  493. — Author's  operating  table  in  Trendelenburg  position. 


Fig.  494. — Portable  operating  table  in  its  case. 


towels  over  their  tops,  plainly  labeled   on  a  strip  of  rubber  ad- 

1  The  18-inch  size  oblong  sterilizer  can  be  packed  and  put  in  the  autoclave,  where 
it  is  sterilized  under  pressure.  It  is  packed  in  a  wooden  case,  transported  to  the 
house,  and  resterilized  just  before  the  operation  on  its  own  pan. 


;84       The  Detailed  Technic  of  Gynecic  Surgery 


Fig.  455. — Portable  operating  table  set  up  for  a  vaginal  operation.. 


Fig.  496. — Portable  operating  table  in  Trendelenburg  position. 


The  Operating  Table 


585 


hesive  plaster  so  that  water  and  sublimate  solutions  shall  not  be 
confused.  Two  small  tables  from  the  household  furniture,  draped 
with  sterile  sheets,  suffice  for  the  instruments  and  pads.  An- 
other table,  similarly  protected,  is  needed  for  the  autoclave  cage 
or  the  steam  sterilizer. 

The   operating    table    should    be    simple    in    construction, 
hght  in  weight,  easily  moved  on  large  rollers,  with  a  quickly  and 


Fig.  497. — Kitchen  table  draped  with  a  sheet  and  Edebohls'  leg  supports  attached. 


easily  managed  hinged  arrangement  for  the  Trendelenburg  pos- 
ture. Supports  for  the  shoulders  are  provided  to  hold  a  patient 
in  the  Trendelenburg  posture,  but  I  do  not  use  them.  An  air- 
cushion  covering  almost  the  whole  length  of  the  table  is  useful, 
as  it  saves  the  patient  a  great  part  of  the  backache  usually  com- 
plained of  after  operation  and  keeps  her  warmer  than  a  glass  or 
iron  surface  would.      It  is  possible,  but  not  advisable,  to  fill  the 


586       The  Detailed  Technic  of  Gynecic  Surgery 

cushion  with  hot  water.  There  is  danger  of  burning  her  back 
if  the  temperature  of  the  water  is  not  carefully  regulated.  The 
table  is  provided  with  the  upright  leg  supports  and  stirrups  for 
the  feet.  A  good  portable  table  is  a  great  convenience  in  private 
house  operations.  The  table  shown  in  figure  495  has  proved  by 
far  the  most  satisfactory  in  the  author's  practice.  It  is  light  (28 
pounds),  portable,  strong,  and  easily  managed,  giving  the  vari- 
ous postures  required  in  gynecic  surgery. 


Fig.  498. — Abdominal 
retractor. 


Fig.  499. — Author's 
sharp-pointed  pedicle 
needles  for  the  bases  of 
the  broad  ligaments. 


Fig.  500. — Author's 
round-pointed  needle  for 
uterine  suspension. 


For  plastic  operations  the  Edebohls'  clamps  and  leg  supports, 
which  can  be  attached  to  any  kitchen  table,  are  a  reasonable 
and  satisfactory  substitute  for  a  specially  constructed  operating 
table.  The  leg-holders,  such  as  Robb's  and  even  Clover's,  are 
unsteady  and  inconvenient. 

Instruments  and  their  Preparation. — For  an  ordinary  ab- 
dominal operation  (salpingo-oophorectomy,  uterine  suspension, 
liysterectomy,  pelvic  abscess,  small  pelvic  or  abdominal  tumors) 


Instruments  and  their  Preparation 


587 


the  following  instruments  are  laid  out:  2  knives;  2  abdominal 
retractors;  i  Thomas' applicator;  i  pair  heavy  straight  abdominal 
scissors;  2  pairs  curved  scissors,  one  heavy,  for  pedicle,  one 
small;  2   Spencer  Well's  forceps;  4  pedicle  needles,  2  sharp,  2 


Fig.  501. — a,  Cleveland's  dilator;   b,  Wathen's  dilator  ;   c,  Goodell's  dilator,  modi- 
fied. 


Fig.  502. — Martin's  curet. 


dull ;  6  safety  pins  ;  2  tissue  forceps  ;  18  hemostats  ;  4  full-curved, 
spear-pointed  needles;  2  curved,  round-pointed,  fine  uterine  sus- 
pension needles ;  3  short  medium-curved,  spear-pointed  needles ; 
2  short  cervix  needles  for  skin.     The  sharp  pedicle  needles  for 


588        The  Detailed  Technic  of  Gynecic  Surgery 

the  bases  of  the  broad  hgament,  to  secure'the  uterine  arteries,  are 
bent  at  angles  on  the  shaft,  one  away  from  the  operator,  to  be 
used  on  the  right  broad  ligament  (if  he  stands  on  the  patient's 
right  side),  the  other  bent  toward  the  operator,  for  the  left  broad 
ligament.      These  angles  make  it  easier  to  dodge  the  ureters. 

For  an  ordinary  plastic  operation  (posterior  and  anterior  col- 
porrhaphy,  trachelorrhaphy,  dilatation  and  curettage)  the  follow- 
ing   instruments    and    materials    are    required:  Wathen's   large. 


Fig-  503- 


-Author's  double  tenacula 
for  the  cervix. 


Fig.  504. — Allis'  forceps. 


Goodell's  small,  and  Cleveland's  four-branched  dilator;  2  double 
tenacula;  2  Allis'  forceps;  i  shot  compressor,  and  perforated 
shot;  2  sharp  Sims'  curets;  i  Martin's  curet;  an  Emmet  curet 
forceps ;  1 8  hemostats ;  intra-uterine  catheter  (Fritsch-Boze- 
man);  i  small  pair  sharp-pointed  scissors ;  i  pair  small  curved 
scissors;  I  rat-tooth  forceps;  I  tissue  forceps;  4  full  round 
curved,  spear-pointed  needles ;  silkworm-gut,  formalin  and 
cumol  catgut;  assorted  sizes  Fmmet  perineum  and  cervix  needles.. 


Special  Instruments 


589 


The  double  tenacula  for  the  cervix  should  have  the  shape 
shown  in  figure  503,  so  as  not  to  pinch  the  cervical  lips.  For 
other  regions  the  Allis'  forceps  are  more  satisfactory  (Fig. 
504).  The  Cleveland  four-branched  dilator  is  much  superior 
to  any  of  the  two-branched  dilators,  but  its  insertion  should 
be  preceded  by  the  use  of  a  small  and  of  a  heavy  dilator, 
the  dilatation  being  carried  to  about  three-fourths  of  an  inch. 
The  four-branched  dilator  should  be  gradually  opened  to  90  mm. 
on  the  scale,  except  in  ill-developed,  infantile  wombs,  in  which  the 
limit  should  be  70  mm.  The  needles  are  round,  full-curved,  spear- 
pointed,  and  the  well-known  Emmet  cervix  and  perineum  needles. 

Special  Instruments For  cauterization  the  Paquelin   cautery 

and  an  electrocautery  cone  are  required.  The  latter  is  in  some 
respects  the  more  satisfactory  and  reliable  instrument.      It  is  at- 


Fig.  505. — Thermocautery. 


tached  to  the  transformer  connected  with  the  electric  light  plant, 
by  a  plug  in  the  wail ;  if  the  current  is  direct,  a  motor  is  needed 
in  addition  to  the  transformer.  The  electrocautery  gives  a  more 
intense  heat  than  the  Paquelin,  is  not  cooled  so  quickly  when 
brought  in  contact  with  bleeding  and  secreting  surfaces  like  a  cer- 
vical cancer,  and  will  not  fail  the  operator  in  the  midst  of  an 
operation,  as  the  Paquelin  sometimes  does. 

The  electrothermic  hemostatic  clamps  of  A.  J.  Downes  are 
an  indispensable  part  of  a  complete  equipment  for  abdominal 
and  pelvic  surgery.  They  are  most  useful  for  clamping  a  broad 
ligament  which  is  not  infiltrated  or  thickened,  for  the  slender 
stump  of  a  pedunculated  tumor,  and  for  the  hemostasis  of  the 
broad  ligament  in  malignant  growths  of  the  uterus. 

For  an  ovarian  or  other  cystic  tumor  a  trocar  is  usually  pro- 


590       The  Detailed  Technic  of  Gynecic  Surgery 

vided,  but  personally  I   rarely  use  it,  preferring  puncture  by  a 
knife. 

Two  specially  constructed  catch  forceps  are  convenient  for 


Fig.  506. — Electrocautery  point. 


Fig.  507. — Thermocautery  points. 


seizing  the  walls  of  an  ovarian  cyst  after  it  has  been  incised  and 
for  pulling  the  tumor  out  of  the  abdominal  wound. 

For  a  large  fibroid  tumor  a  heavy  volsella  forceps  is  needed 
to  make  traction  on  the  tumor  and  to  steady  it. 

It  is  convenient  to  have  an  instrument  tray  divided  into  com- 
partments for  the  different  instruments,  so  that  the  assistant  can 


Dressings  and  the  Packing  of  the  Autoclaves    591 

lay  his  hands  on  what  he  wants  without  delay.  There  should  be 
a  separate  pan  for  the  suture  material  and  needles. 

All  the  instruments  except  the  knives  are  boiled  for  half  an 
hour.  The  knives,  with  their  blades  wrapped  in  cotton,  are 
dropped  in  the  boiling  water  for  the  last  five  or  ten  minutes.  A 
small  piece  of  washing-soda  in  the  water  keeps  the  instruments 
from  rusting.  The  silkworm-gut  for  suture  material  is  also 
sterilized  by  boiling  water,  but  it  can  not  be  boiled  in  the  water 
with  the  instruments,  for  the  soda  makes  it  soft  and  brittle. 

Dressings  and  the  Packing  of  the  Autoclaves. — The  cage  of 
one  autoclave  is  packed  from  the  bottom  up  with  the  following 
materials  in  regular  order  for  an  abdominal  section : 

Packing  Cage  for  Autoclave  No.  1. — One  abdominal  binder  of 


Fig.  508. — Transformer  for  electrocautery  point  and  Downes'  forceps. 


outing  flannel;  4  pieces  absorbent  cotton;  12  pieces  of  gauze; 
I  book  of  silver  foil ;  1 2  towels ;  2  tubes  of  silk ;  i  glass  tube 
filled  with  six-inch  gauze  bandage  for  packing;  also  a  three-inch 
rolled  bandage ;  4  sheets ;  3  gowns ;  3  caps,  or  squares  of 
gauze  for  the  head;   3  nail  brushes. 

The  second  autoclave  without  a  cage  is  packed  from  within 
outward,  as  follows : 

Autoclave  No.  2. — Three  small  basins ;  I  package  wrapped  in 
gauze,  containing  fifteen  pads  for  sponges ;  i  pan  for  sutures  and 
needles ;  2  small  white  enameled  pitchers ;  i  tube  of  catgut ;  3 
nail  brushes  ;  jar  of  alcohol  with  tight  screw-cap  (to  wash  abdo- 
men with)  ;  bottle  of  glycerin  for  rubber  gloves  ;  small  jar  of 
olive  oil  for  Downes'  clamps. 


592       The  Detailed  Technic  of  Gynecic  Surgery 

The  gauze  pads  are  provided  in  an  invariable  number.      I  use 
fifteen:  one  large,  9X9  inches;  seven   medium,  4  X  4  inches; 


Fig.  509. — Downes'  electro- 
thermic  hemostatic  clamp. 


Fig.  510. — Protector 
for  electrothermic  clamp 
to  guard  adjacent  tissues 
from  the  heat. 


Fig.  511. — Author's 
catch  forceps  for  wall  of 
cystic  tumor. 


Fig.  512. — Trocar  for  cystic  tumors. 


and  seven  small,  3X3  inches,  in  sixteen  to  thirty  layers.  By 
using  an  invariable  number  the  nurse  who  prepares  the  package 
has  no  excuse  for  a  mistake  in  this  respect,  and  by  making  this 


Sutures  and   Lisjatures 


593 


number  as  small  as  practicable,  time  and  trouble  are  saved  in  the 
final  count  of  the  pads. 

For  a  plastic  operation  the  following  articles  are  omitted  from 
the  autoclaves:  From  No.  i,  the  abdominal  binder,  tubes  of  silk, 
pieces  of  gauze,  and  the  silver  foil;  a  fenestrated  sheet  is  added. 
From  No.  2,  the  gauze  pads.  For  plastic  operations  sea  sponges 
are  preferable  and  are  safe  if  soaked  over  night  in  a  i  :  1000  sub- 
limate solution.     They  are  used  once  only. 

Sutures  and   Ligatures. — Cumol  and  formalin  catgut,  silk- 


Fig.  513- — Instrument  tray  divided  into  compartments 


worm-gut,  and  the  two  smaller  sizes  of  Tait's  twisted  Bir- 
mingham silk  are  the  materials  required  for  sutures  and  liga- 
tures. ^ 

Cumol  gut  has  the  advantages  of  great  tensile  strength  and 
a  very  short  durability.  It  is  the  ideal  ligature,  therefore,  in  all 
septic  and  infectious  cases,  as  it  is  desirable  to  have  it  disappear 

1  Kangaroo-tendon  is  no  stronger  or  more  durable  than  properly  prepared  catgut 
and  is  more  difficult  to  sterilize.  Iron  dyed  (black)  ligatures  are  recommended  be- 
cause they  are  more  easily  visible.     I  do  not  find  them  necessary. 


594       The  Detailed  Technic  of  Gynecic  Surgery 

as  soon  as  possible  after  48  hours.  It  was  first  prepared  by 
Kronig,  whose  process  was  modified  and  improved  by  Clark 
and  Miller.  The  process  is  conducted  as  follows:  Kronig's 
method:  (i)  Roll  the  catgut  in  rings.  (2)  Dry  it  in  a  hot-air 
oven  or  over  a  sand-bath  for  two  hours  at  70°  C.  (3)  Heat  it  in 
cumol   to   a  temperature  (165°  C.)  a  little  short  of  the  boiling- 


Fig.   514. — Heavy  volsella  for- 
ceps for  fibroid  tumors. 


Fig-  515- — Gauze 
bandage  packed  in 
glass  tube  stoppered 
with  cotton. 


Fig.    516. — Cumol 
gut  in  sterile  tube. 


point,  for  one  hour.  (4)  Transfer  it  to  petroleum  benzine  for 
permanent  preservation,  or,  if  desirable,  leave  it  in  benzine  for 
three  hours,  and  transfer  to  sterile  Petri  dishes.  A  bacterio- 
logical study  of  this  method  by  Clark  and  Miller  shows  that  the 
sterilization  is  perfect,  but  that  the  transference  from  boiling 
cumol  to  benzine  is  open  to  serious  objection.  Clark  and  Miller 
found  that  benzine   is  not  a  germicide;  also  that  it  can  not  be 


Preparation  of  Silk  595 

rendered  sterile  by  heat  without  danger,  and,  therefore,  modified 
Kronig's  method  as  follows:  (i)  Roll  the  catgut,  twelve  strands, 
in  figure-of-eight  form,  so  that  it  can  be  slipped  into  a  large 
test-tube.  (2)  Bring  the  catgut  up  to  a  temperature  of  80° 
C,  and  hold  it  at  this  point  for  one  hour.  (3)  Place  in 
cumol,  which  must  not  be  above  100°  C,  raise  it  to  165°  C,  and 
hold  it  at  this  point  for  one  hour.  (4)  Draw  off  the  cumol,  and 
either  allow  the  heat  of  the  sand-bath  to  dry  the  catgut,  or 
transfer  it  to  a  hot-air  oven,  at  a  temperature  of  100  C,  for  two 
hours.  (5)  Transfer  the  rings  with  sterile  forceps  to  test-tubes 
previously  sterilized.  In  drying  or  boiling,  the  catgut  should  not 
come  in  contact  with  the  bottom  or  sides  of  the  vessel,  but  should 
be  suspended  on  slender  wire  supports,  or  placed  upon  cotton 
loosely  packed  in  the  bottom  of  the  beaker  glass. 

Formalin  gut  prepared  as  described  below  has  the  advantage 
of  no  handling  in   the   course  of  preparation,    absolute  sterility 


Fig-  S^7- — Gauze  pads  (fifteen)  wrapped  in  sterile  gauze  package. 

as  it  comes  from  the  autoclave,  boiled  in  glycerin  and  alcohol  at 
240°  F.,  and  a  durability  of  three  weeks.  If  the  cap  of  the 
metal  tube  is  not  provided  with  a  good  washer  and  is  not 
screwed  tight,  the  gut  is  ruined. 

Preparation  of  Formalin  Catgut  (Sizes  o  and  3). — Soak  twelve 
hours  in  benzine;  dry  twelve  hours  on  blotting  paper;  put  in 
cold  sterile  water  for  two  hours,  rolled  loosely  on  some  cylindri- 
cal object,  then  in  a  solution  of  i  :  20  formalin  for  sixteen  hours; 
rinse  off  thoroughly  in  running  water  and  stretch  tight  on  a 
wooden  frame  to  dry  for  four  or  five  days.  The  frame  is  placed 
in  a  clean  pillow-case  to  keep  it  from  accumulating  dust.  The 
catgut  is  cut  off  in  sutures  thirty-six  inches  in  length,  rolled  on 
wooden  spools,  five  fine,  five  coarse  strands  on  each  spool ;  put 
in  metal  tube  in  absolute  alcohol  nine  parts,  glycerin  one  part, 
with  cap  screwed  on  as  tightly  as  possible. 

Preparation  of  Silk. — Tait's  Birmingham  silk  :  sizes  medium 
and  fine,  cut  in  sutures  thirty-six  inches  in  length;  three  strands 


596       The  Detailed  Technic  of  Gynecic  Surgery 

rolled  on  a  glass  spool ;  one  spool  of  fine  and  two  spools  of 
medium  size,  put  in  a  glass  tube,  the  end  being  plugged  with 
cotton  ;  sterilize  in  autoclav^e,  at  temperature  240°  F.  for  forty- 
five  minutes,  then  dry  in  a  hot-air  oven  one  hour,  temperature 
I  50°  F.  The  tubes  are  kept  plugged  in  a  glass  jar,  ready  for 
resterilization  in  autoclave  for  each  operation. 

The  silkworm-gut  should  be  the  thickest  and  strongest  sold  in 


Fig.  518. — a.  Formalin  gut  on  frame; 
b,  metal  tube  for  sterilizing  the  gut ;  c,  wooden 
spool  on  which  it  is  wrapped. 


Fig.  519. — Silk  in  glass  tube, 
on  glass  reels  ;  the  tube  is  stoppered 
with  cotton. 


the  shops.  The  strands  are,  therefore,  rather  short.  The  longer 
the  strand,  as  a  rule,  the  more  fragile  the  gut.  Silkworm-gut  is 
sterilized  in  boiling  water,  for  ten  to  thirty  minutes.  The  water 
should  have  no  soda  in  it. 

The  Preliminary  Treatment  and  Examination  of  the 
Patient. — A  Avoman  should  be  in  the  hospital  forty-eight  hours 
before   operation.      On    entering,   if  she  is   a   ward    patient,   she 


Preliminary  Treatment  and  Examination        597 

takes  a  full  bath,  superintended  by  a  nurse.  Her  heart  and 
lungs  are  examined.  The  total  amount  of  urine  is  collected  for 
the  t\vent\'-four  hours,  and  on  two  successive  days  is  examined 
for  albumin,  sugar,  casts,  specific  gravity,  and  urea  percentage  (by 
Doremus'  apparatus).  The  blood  is  examined  for  the  number  of 
red  and  white  corpuscles  and  for  hemoglobin  percentage. 

The  existence  of  a  drug  habit  should  be  ascertained,  if  pos- 
sible. If  sedatives  or  stimulants  have  been  habitually  taken,  they 
must  be  continued  in  diminishing  doses  for  several  days  after  the 
operation. 

If  there  is  evidence  of  kidney  disease  an  operation  of  elec- 
tion should  usually  be  postponed  until  dietetic  and  eliminative 
treatment  has  brought  about  a  marked  improvement  in,  or  an 
entire  disappearance  of,  the  symptoms.  If  there  is  no  decided  im- 
provement, the  operation  should  not  be  undertaken.  In  an 
operation  of  necessity  the  risk  of  uremia  or  diabetic  coma  must 
be  incurred,  although,  if  possible,  time  should  be  allowed  for 
some  improvement  by  treatment.  The  risk  of  uremia  is  not 
great  with  proper  precautions  in  the  use  of  anesthetics.  The 
risk  of  diabetic  coma  is  considerable.  Noble's  collected  statistics 
show  a  mortality  of  24.28  per  cent,  in  70  cases  operated  upon 
with  sugar  in  the  urine.  ^  Beyea  reports  a  case  of  ovarian  cyst 
in  which  sugar  disappeared  from  the  urine  after  the  operation.  ^ 

If  there  is  evidence  of  leukemia  no  opei'ation  should  be  un- 
dertaken if  it  can  possibly  be  avoided.  A  leukemic  subject  does 
not  stand  the  prick  of  a  hypodermic  needle  well.  A  temporary 
leukocytosis  naturally  does  not  forbid  an  operation,  but  is,  on  the 
contrary,  frequently  a  positive  indication  for  it.  Anemia  is 
unfavorable  for  operative  w^ork.  A  hemoglobin  percentage 
below  30  is  said  to  contraindicate  anesthetization,  but  in  fibroid 
tumors,  in  other  causes  of  metrorrhagia,  and  in  sepsis,  a  capital 
operation  must  sometimes  be  undertaken  with  a  percentage  as 
low  as  10.  Treatment  should  be  instituted,  if  possible,  to 
improve  the  blood  condition  before  the  operation ;  just  before 
anesthetization  there  should  be  a  submammary  injection  of  a  pint 
of  normal  salt  solution  under  each  breast  and  a  hypodermatic  injec- 
tion of  digitalis  and  strychnia ;  the  anesthetic  should  be  given  in 
as  small  amounts  and  for  as  short  a  time  as  possible ;  hemostasis 
in  the  operation  should  be  perfect,  and  the  utmost  celerity 
consistent  with  good  work  is  essential.  If  there  is  cardiac  dis- 
ease it  is  often  an  anxious  question  whether  an  operation  should 
be    attempted.       If    compensation    is    good    and    there    is    not 

1  Three  deaths  from  sepsis  ;  5,  cause  not  stated  ;  9  from  coma.  (Personal  com- 
munication. ) 

-  "Tr.  Gyn.  Sect.,  College  of  Physicians,"  vol.  v. 


598       The  Detailed  Technic  of  Gynecic  Surgery 

much  dilatation,  the  cardiac  condition  should  give  the  oper- 
ator little  concern.  Preliminary  treatment  with  strophanthus  or 
digitalis  and  complete  rest  is  often  advisable.  After  the  opera- 
tion cardiac  stimulants  are  given  routinely  only  in  case  of  rapid, 
feeble,  or  irregular  heart -action.  There  is  danger  of  overstimu- 
lating  the  heart  if  the  operator  allows  himself  to  become  too 
apprehensive  because  he  is  aware  that  a  cardiac  lesion  exists. 

An  acute  inflammatory  process  in  the  lungs  is  naturally 
a  contraindication  to  an  operation.  In  incipient  tuberculosis, 
however,  an  operation  of  election  may  be  deliberately  undertaken 
with  the  object  of  increasing  the  patient's  activity  and  ability  to 
move  about  in  the  open  air. 

The  medicinal  treatment  routinely  prescribed  for  all  patients 
about  to  be  operated  upon  in  the  author's  clinics  is  as  follows :  A 
pill  of  strychnia  (gr.  ■J^).and  digitalis  (gr.  }4),  t  i.  d.;  2  drams  of 
Rochelle's  salts  in  a  tumbler  of  water  the  evening  after  admis- 
sion; 15  grains  of  sulfonal  at  5  o'clock  the  afternoon  before 
operation;  at  9  P.  M.,  half  an  ounce  of  Epsom  salts  in  a  tumbler 
of  water,  followed  the  next  morning  by  a  simple  enema,  or, 
if  there  is  to  be  a  plastic  operation,  by  repeated  enemata  till  the 
lower  bowel  is  empty. 

The  diet  the  day  before  operation  is  gruel  for  breakfast,  soup 
for  dinner,  milk  toast  for  supper;  one  glass  of  milk  at  10  a.  m. 
and  4  p.  M.  The  morning  of  the  operation,  at  7  o'clock,  the 
patient  receives  2  ounces  of  clear  beef-tea. 

Hand  and  Skin  Cleansing. ^ — There  is  no  known  method 
by  which  the  human  skin  can  be  made  sterile.  It  can  be  so  well 
cleansed,  however,  as  not  to  be  a  dangerous  source  of  infection 
unless  the  operator  has  contaminated  his  unprotected  hands  with 
some  particularly  virulent  micro-organism,  such  as  the  strepto- 
coccus of  purulent  peritonitis.  The  question  of  the  best  method 
of  hand  cleansing  is  not  now  such  an  anxious  one,  as  the  sur- 
geon must  wear  rubber  gloves  uniformly,  no  matter  what  system 
of  skin  cleansing  he  uses.  The  insertion  of  the  bare  hand  in  a 
wound  is  unjustifiable  in  the  light  of  our  present  knowledge.  But 
the  gloves  may  be  pricked  or  torn  during  an  operation,  so  that  the 
hands  under  them  must  be  made  as  clean  as  it  is  possible  to  get 
them.  The  skin  must  be  freed  of  all  superficial  epidermis 
scales;  the  sebaceous  matter  must  be  removed  not  only  from 
the  surface,  but  from  the  crypts  in  the  skin  ;  the  nails  and  palmar 
surfaces  of  the  fingers  should  receive  particular  attention.  The 
method  should  be  as  simple  and  uncomplicated  as  is  consistent 
with  the  best  results.      Such  a  system,  for  example,  as  immersing 

'  See  "  Hanflereinigung,  Handedesinfektion,  und  TIaiideschutz,"  Haegler, 
1900;  and  '-Beitrage  zur  ilaiidedesinfektionsfrage,  Scliaefier,  1902. 


Hand  and  Skin   Cleansing- 


599 


the  hands  and  arms  in  permanganate  solution  and  then  bleaching 
them  in  oxalic  acid  solution,  when  neither  the  permanganate  so- 
lution nor  the  oxalic  acid  solution  is  an  efficient  germicide, 
is  illogical,  wastes  time,  and  requires  the  preparation  in  bulk  of 
two  extra  solutions  which  are  unnecessary. 

The  following  system  has  been  employed  by  the  author  for 
the  last  eight  years  because  he  believes  it  to  be  efficient  and  not 
too  complicated  and  because  the  bacteriological  examinations 
have  shown  as  sterile  a  condition  of  the  skin  as  is  secured  by 
any    method.       Three    sterile    basins,    three    small,    two    large 


Fig.    520. — Arrangement  for  hand   cleansing.      Three  basins  for  sterile  water,  two 
glass  dishes  for  benzine  and  alcohol,  and  tub  for  sublimate  solution. 


glass  dishes,  and  a  tub  (for  sublimate  solution)  are  provided.  Six 
brushes  are  sterilized  in  the  autoclave.  The  three  basins,  each 
with  a  small  glass  dish  of  tincture  of  green  soap  beside  it,  are 
placed  in  a  long  trough,  in  front  of  which  the  operator  and  his 
two  assistants  stand  side  by  side. 

The  nails  are  cut  short.  The  hands  and  arms  to  the  elbow 
are  scrubbed  for  ten  minutes  by  the  clock  with  stedle  brush, 
tincture  of  green  soap,  and  with  four  changes  of  sterile  w^ater,  a 
imrse  empt}-ing  the  basins  by  catching  them  outside  of  and 
below  the  brim  and  fiUino-  them  aeain  with  sterile  w^ater  from  a 


6oo       The  Detailed  Technic  of  Gynecic  Surgery 

sterile  pitcher  (boiled  in  the  implement  sterilizer).  Fresh  brushes 
are  then  taken  from  the  autoclave  cage ;  the  hands  and  arms  are 
next  scrubbed  with  benzine, ^  then  with  alcohol,  and  are  finally 
immersed  for  a  minute  or  two  in  a  i  :  looo  sublimate  solution. 
The  whole  process  lasts  fifteen  minutes.  One  cleansing  ordina- 
rily suffices  for  an  operating  day.  Ten  to  twenty  operations  on 
six  to  eight  patients  in  succession  are  performed  with  a  change 
of  gowns  and  gloves  after  each  operation. 

The  Preparation  of  the  Patient  for  an  Abdominal  Section. 
—  The  Afternoon  before  Operation  ;  Skin  Cleansing. — Prepare 
rubber  gloves  by  wrapping  in  gauze  and  boiling  for  five  to  ten 


Fig.  521. — Gauze  pad  for  patient's  abdomen,  extending  part  way  down  the  thighs. 


minutes.  Clip  pubic  hair  with  clipper  and  shave  with  a  safety 
razor.  Sterilize  the  following  articles  for  forty-five  minutes  at 
240°  F  :  Two  hand  brushes  for  nurse;  two  soft-bristle  brushes 
for  patient;  absorbent  cotton;  four  small  sheets;  one-half  dozen 
towels;  gauze,  unmedicated;  gauze  pad;  binder;  long-sleeved 
gown. 

The  nurse  who  cleanses  the  abdomen  must  prepare  her 
hands  and  arms  as  though  about  to  operate,  namely:  cut  nails 
short;   scrub  hands  and  arms  with  brush,  hot  water,  and  tincture 

1  The  quantity  of  sel^aceous  matter  removed  from  the  skin  by  this  agent  can  be 
demonstrated  by  letting  the  benzine  evaporate  after  the  operator  and  his  assistants 
have  scrubbed  their  hands  and  arms  in  a  pint  or  more  of  it.  There  is  no  other 
material  so  efficient  for  the  jjurpose. 


Preparation   for  Abdominal  Section 


60 1 


of  green  soap  for  ten  minutes,  with  four  changes  of  sterile  water 
in  sterile  basin  ;  clean  nails  with  boiled  nail  file ;  with  fresh  brush 
scrub  hands  and  arms  with  benzine  and  then  with  alcohol; 
immerse  hands  and  arms  in  bichlorid  solution  (i  :  looo)  for  two 
minutes.      Then  put  on  the  long-sleeved  gown  and  gloves. 

The  abdomen,  from  ensiform  to  symphysis  and  from  flank  to 
flank  and  one-third  the  way  down  the  thighs,  must  be  scrubbed 
with  soft-bristle  brush,  tincture  of 
green  soap,  and  hot  water,  thoroughly 
(for  ten  minutes  by  the  watch,  with 
four  changes  of  sterile  water),  paying 
special  attention  to  navel  and  to  pubic 
regions.  Scrub  thoroughly  with  alco- 
hol with  the  second  sterile  soft-bristle 
brush.  Cover  the  abdomen  with  the 
sterile  gauze  pad,  and  put  on  the 
binder. 

Morning  of  the  Operation. — Give 
2  ounces  of  clear  beef- tea  at  7  o'clock  ; 
give  enema  of  pint  of  soapsuds,  i  dram 
of  turpentine.  Hands  of  nurse  cleansed 
as  described  above.  Articles  resteril- 
ized  as  described  above.  Same  cleans- 
ing of  abdomen  repeated  as  described 
above,  but,  in  addition:  before  alcohol 
scrubbing,  scrub  abdomen  with  ben- 
zine; wring  out  the  large  sterile  gauze 
pad  in  i  :  1000  bichlorid  solution,  and 
cover  the  abdomen  with  it;  put  over 
it  a  thick  layer  of  sterile  cotton ; 
apply  binder.  Catheterize  the  woman 
just  before  anesthetization  with  sterile 
glass  catheter  (in  all  cases  of  abdom- 
inal tumor  the  long  silk  or  rubber 
catheter,  1  previously  boiled,  to  be 
used)  in  aseptic  manner.  Give  vag- 
inal douche,  I  quart  of  I  :  4000  solu- 
tion, followed  by  a  little  sterile  water. 

Pack  the  vagina  with  sterile  gauze.  Packing  always  to  be  re- 
moved in  twenty-four  hours  at  most  or  directly  after  the  operation. 

The  patient  is  dressed  for  the  operation  in  Canton  flannel  leg- 
gings covering  the  feet  and  reaching  to  the  hips,  and  in  a  short 
gown,  open  down  the  back,  reaching  only  to  the  hips. 

1  In  cases  of  abdominal  tumor  the  bladder  is  sometimes  sacculated  or  lifted  high 
into  the  abdomen,  and  a  short  catheter  will  not  evacuate  it. 


Fig.  522. — Canton  flannel 
legging. 


6o2       The  Detailed  Technic  of  Gynecic  Surgery 

The  Preparation  of  the  Patient  for  a  Plastic  Operation. — 

Evening  before. — Sulfonal,  gr.  xv,  at  5  o'clock,  in  one-half  glass 
of  boiling  water,  cooled  down  to  drinking-point.  Epsom  salt, 
one-half  ounce  in  tumbler  of  water  at  9  o'clock. 

Morning'  of  Operation. — Cup  of  beef-tea  at  7  o'clock.  Enema 
•of  soapsuds  and  turpentine.  Irrigation  of  lower  bowel  by  re- 
peated injections,  until  it  is  completely  emptied.  Wash  pubis  and 
labia  with  gloved  hands,  tincture  of  green  soap,  hot  water,  and 
pledgets  of  sterile  cotton.  Shave  pubis  and  labia.  Wash  out 
vagina  with  tincture  of  green  soap  and  pledgets  of  cotton.  Give 
douche  of  i  14000  bichiorid  solution  followed  by  sterile  water; 
tampon  vagina  with  sterile  gauze.  Catheterize  patient  just  before 
anesthetization  with  sterile  glass  catheter  in  aseptic  manner. 

If  a  vaginal  tampon  is  inserted  after  an  operation,  it  mnst 
never  be  left  in  longer  than  tzventyfoiir  hours,  except  by  order  of 
the  chief  Douches  after  a  plastic  operation  to  be  given  only  by 
order  of  the  chief  The  number  of  stitches  to  be  removed  must 
invariably  be  noted  on  the  chart. 

The  Preparation  of  the  Surgeon ;  Clothes,  Gowns,  and 
Gloves. — Three  suits  of  cheviot  shirt  and  duck  trousers  or 
pajamas  are  folded  neatly,  wrapped  in  a  towel,  which  is  pinned 
securel}-.  Each  bundle  is  marked  with  the  names  of  the  operator 
and  his  two  assistants,  is  sterilized  in  the  autoclave,  and  placed 
in  the  dressing  room  adjoining  or  near  the  operating  room. 
Canvas  shoes  Avith  rubber  soles  are  also  provided.  The  operator 
and  his  assistants  change  all  of  their  outer  clothes  and  shoes. 
The  gowns  must  have  long  sleeves  down  to  the  wrist,  fitting 
.snugly  so  that  they  will  not  ride  up  during  the  operation.  The 
rubber  gloves  should  have  gauntlets,  to  turn  up  over  the  wrist- 
bands of  the  gowns.  No  skin  surface  of  the  operator  or  his 
assistants  shall  be  exposed.  The  head  is  tied  with  a  triangular 
piece  of  gauze,  to  cover  the  hair  and  to  catch  the  perspiration 
from  the  forehead.  It  is  a  sensible  practice  to  cover  the  nose 
and  mouth  with  a  strip  of  folded  gauze  tied  around  the  back  of 
the  neck.  Edebohls'  experience  of  fatally  infecting  a  patient's 
wound  because  he  had  incipient  diphtheria  would  justify  this 
practice  as  a  routine  measure,  but  it  is  so  uncomfortable  that  the 
author  only  resorts  to  it  if  he  has  a  cold,  sore  throat,  or  feels  in- 
disposed. The  gloves  are  sterilized  by  boiling  for  ten  minutes: 
each  pair  is  wrapped  in  a  piece  of  gauze.  They  are  spilled 
from  the  vessel  in  which  they  have  been  boiled  into  a  tub  of 
sterile  water.  Sterile  glycerin  is  poured  into  the  gauntlet  to  facili- 
tate the  insertion  of  the  hand.  They  are  rinsed  off  in  a  bichiorid 
.solution  (i  :  1000)  after  they  are  put  on.      In  putting  them  on, 


Anesthesia  and  Anesthetics 


603 


the  fingers  and  palmar  surfaces  are  not  touched.  They  are  held 
by  the  gauntlets  and  wrists.  Extravagance  in  the  matter  of 
gloves  is  essential  to  a  good  technic.  Six  pairs  are  prepared  for 
every  operation,  so  that  a  change  is  provided  for  the  operator 
and  two  assistants  in  the  midst  of  the  operation  if  it  is  desired. 
Twelve  pairs  at  least  are  needed  for  a  busy  operating  day,  those 
not  in  use  being  boiled,  and  the  tub  being  constantly  supplied 
with  an  ample  number  for  repeated  changes. 

Anesthesia  and  Anesthetics. — Anesthesia  means  etymolog- 
ically   the   loss   of  tactile  sensibility.      It  is  a  local  or  constitu- 


Fi>. 


523. — a.  Long-sleeved  gown  ;   h,  the  same,  showing  glove  with  gauntlet  turned 
up  over  wristband  of  gown. 


tional  condition  induced  to  avoid  or  control  pain,  to  relieve 
spasm,  and  to  facilitate  surgical  operations. 

Of  a  large  number  of  local  anesthetics,  but  three  are  widely 
used — ethyl  chlorid,  eucain,  and  cocain. 

Ethyl  chlorid  is  kept  in  closed  tubes,  with  adjustable  valves. 
When  the  valve  is  opened,  the  liquid  escapes  in  a  fine  spray  and 
by  rapid  evaporation  freezes  the  skin.  Its  use  is  limited  to  minor 
short  operations,  as  opening  boils  and  extirpating  wens. 


6o4       The  Detailed  Technic  of  Gynecic  Surgery 


Cocain  is  readily  absorbed  by  mucous  membranes,  but  to  an- 
esthetize the  skin  it  must  be  given  hypodermatically.  It  para- 
lyzes the  peripheral  nerve-endings,  is  used  in  solutions  up  to  20 
per  cent.,  and  is  the  best  local  anesthetic.  Its  use  should  be 
confined  to  minor  operations,  however,  except  in  the  very  few- 
cases  where  all  constitutional  anesthetics  are  positively  contrain- 
dicated,  as  in  grave  heart  or  kidney  disease.  One  grain  in 
solution  injected  into  the  spinal  arachnoid  space  posteriorly 
at   the  middle  of  a  line  joining  the  crests  of  the  ilia  anesthetizes 

everything  below  the  waist- 
line, and  if  done  aseptically 
is  reasonably  safe,  success- 
ful, and  occasionally  justifi- 
able. As  a  local  anesthetic 
cocain  is  of  great  service. 
Its  principal  use  in  gyneco- 
logical operations  is  in  dilata- 
tion of  the  cervix  and  primary 
perineorrhaphy.  One-eighth 
grain  cocain  hydrochlorate 
in  solution  injected  in  each 
side  of  the  cervix  permits  its 
dilatation  with  little  or  no 
discomfort.  A  pledget  of 
cotton  saturated  with  4  per 
cent,  solution  of  cocain  and 
placed  in  the  sulcus  of  any 
fresh  perineal  tear  makes  its 
primary  repair  after  two  min- 
utes practically  painless.  Even 
a  complete  tear  may  be  re- 
paired by  this  method. 

Eucain  acts  like  cocain, 
but  is  less  dangerous,  of  more 
lasting  effect,  and  is  not  de- 
composed by  boiling.  It  is, 
however,  less  certain  in  its  effect  and  must  be  used  in  twice  the 
strength.  Its  chief  use  is  for  infiltration-anesthesia  in  a  solution 
composed  of /5-eucain,  o.  i  ;  NaCl,  0.8;  water,  100.  To  avoid 
poisoning  from  cocain  or  eucain,  not  more  than  one  grain  of  the 
former  or  two  of  the  latter  should  be  injected  at  once.  If 
poisoning  does  occur,  whisky,  digitalis,  aromatic  spirits  of  ammo- 
nia, and  strychnin  are  indicated. 

For  minor  operations,  such  as  curettage  and  primary  repairs, 
an  admirable  method  for  both  patient  and  surgeon  is  that  of  com- 


Fig.  524. — Apparatus  for  administerin 
nitrous  oxid  gas  and  oxygen. 


Anesthesia  and   Anesthetics 


605 


billing  laughing  gas  and  oxygen,  h'or  this  purpose  the  S.  S.  White 
Dental  Company,  of  Philadelphia,  furnishes  a  convenient  apparatus. 
A  metal  stand  (Fig.  524)  supports  two  cylinders  of  gas  and  one  of 
oxygen.  One  gas  cylinder  is  used  and  the  other  kept  as  a  reserve 
in  case  the  valve  of  the  first  becomes  obstructed  or  the  cylinder  be- 
comes empty  after  being  used  a  number  of  times.  As  the  gas  and 
oxygen  are  allowed  by  valves  to  escape  from  their  elastic  receptacles 
into  a  common  tube,  they  can  be  mixed  in  any  desired  percent- 
age up  to  ten,  according  to  the  indicator  on  the  oxygen  side. 
Pure  oxygen  can  be  given  by  closing  the  control  valves  on  the 
gas  side.  The  best  plan  is  to  give  the  patient  pure  gas  until  the 
first  appearance  of  cyan- 
osis, with  muscular  or  re- 
spiratory disturbance,  then 
to  admit  oxygen  in  just 
sufificient  amount  to  give 
the  patient  a  healthy  pink 
color.  By  carefully  regu- 
lating the  mixture  of  oxy- 
gen and  gas  the  patient  can 
be  kept  perfectly  quiet  and 
safely  anesthetized  for  half 
an  hour  or  more.  When 
the  surgeon  announces  that 
the  operation  is  finished,  the 
gas  is  turned  off  and  the 
patient  is  allowed  to  inhale  a  few  breaths  of  pure  oxygen.  The 
instant  the  inhaler  is  removed,  the  patient  often  smiles  and  answers 
questions  with  perfect  composure. 

The  best  method  of  producing  constitutional  anesthesia  is  to 
begin  the  anesthesia  by  hyponitrous  oxid  and  to  continue  it  with 
ether.  Eth}d  chlorid  and  chloroform  have  been  substituted  for 
the  gas,  but  they  are  more  dangerous  than  gas  and  ether.  We 
have  given  ethyl  chlorid  a  thorough  trial.  It  takes  twice  as  long 
to  produce  the  same  results  as  the  nitrous  oxid  gas,  and  it  is 
followed  sometimes  by  long-continued  and  violent  vomiting.  It 
has  the  advantage  of  being  much  more  easily  portable  than  the 
gas  apparatus,  so  that  we  use  it  in  preference  sometimes  in  pri- 
vate houses.  It  is  probably  safer  than  chloroform,  though  the 
statistics  include  a  very  large  number  of  cases  in  which  it  was 
used  for  only  a  few  moments  in  dental  operations.  ^      With  mixed 

1  See  "Ethyl  Chlorid  as  a  .General  Anaesthetic,"  W.  J.  McCardie,  London 
"Lancet,"  April  4,  1903.  Seitz's  statistics  of  I  death  in  16,000  administrations 
are  quoted.  There  is  a  useful  table  of  the  comparative  danger  of  the  anesthetics  in 
common   use.      They    rank  in    this    order :    nitrous  oxid    gas,  ethyl    chlorid,   ether, 


Fig.  525. — Portable  apparatus  for  nitrous  oxid 
gas. 


6o6       The  Detailed  Technic  of  Gynecic  Surgery 

anesthetics  we  have  as  }'et  no  experience.  Mixtures  of  alcohol, 
chloroform,  and  ether  (A.  C.  E.  mixture  in  proportion  of  volume 
I.  2,  3),  chloroform  and  ether,  and  chloroform,  ether,  and  benzine 
(Schleich)  have  been  advocated,  but  they  do  not  appeal  to  our 
reason.  The  most  sensible  proposition  on  these  lines  has  been 
made  by  Willy  Meyer, ^  following  Schleich's  reasoning:  A  mix- 
ture is  made  of  chloroform,  43.25,  and  ether,  56.75  parts  by 
volume;  83  parts  by  volume  of  this  mixture  and  17  parts  of  ethyl 
chlorid  give  an  anesthetic  mixture  (anesthol)  with  a  boiling-point 
of  104°  F.,  or  nearly  that  of  the  body-temperature.  This 
mixture  is  absorbed  and  eHminated  with  equal  facility,  and  there- 


Fig.  526. — Mask  and  tube  for  ethyl  chlorid. 

fore,  it  is  claimed,  is  safer  than  any  one  of  its  component  parts 
alone. 

For  general  use  a  portable  gas  apparatus  is  desirable.  The 
best  apparatus  for  this  purpose  is  shown  in  figure  525.  It  com- 
prises a  filled  cylinder  containing  one  hundred  gallons  of  nitrous 
oxid  gas,  an  elastic  receptacle,  tube,  and  inhaler.  The  inhaler 
has  a  pliable  metal  frame  lined  with  soft  rubber  and  surrounded  by 
a  pneumatic  tube  which  allows  its  close  approximation  to  the  face. 
The  inhaler  has  an  inspiratory  and  an   expiratory  valve  and  a 

chloroform,  and  bromid  of  ethyl.      The  last  has  such  a  high  mortality  that  its  use  is 
scarcely  justifiable. 

^  "Jour.  Am.  Med.  Assoc,"  ¥ch.  28,  March  7,  I903. 


Anesthesia  and  Anesthetics  607 

thumb  spring  valve  to  control  the  gas.  When  the  cylinder  valve  is 
opened  by  a  thumbscrew,  the  liquid  vaporizes  as  it  escapes  into 
an  elastic  receptacle.  This  makes  the  administration  constant 
and  regular.  One  cylinder  is  sufficient,  generally,  to  anesthetize 
ten  patients.  When  a  cylinder  has  been  used  a  number  of  times, 
however,  it  is  always  well  to  have  attached  a  reserve  cylinder 
which  may  be  emptied  into  the  same  receptacle,  so  that  when 
one  cylinder  is  empty  the  anesthesia  will  not  be  interrupted. 

The  patient  must  be  in  a  recumbent  posture  and  have  nothing 
loose  in  the  mouth.  All  obstructions  to  free  respiratory  move- 
ments must  be  removed,  and  there  should  be  a  good  light  so  that 
the  patient's  color  and  movements  may  be  quickly  and  accurately 
observed.  The  patient's  heart  is  superficially  examined,  not 
only  to  test  its  action,  but  also  to  gain  her  confidence.  She 
should  be  assured  that  there  is  no  danger,  but  that  she  will 
simply  fall  quietly  to  sleep.  With  quiet,  deep  breathing,  the  an- 
esthesia may  be  easily,  quickly,  and  safely  induced.  It  has  been 
claimed  that  certain  patients  are  not  susceptible  to  nitrous  oxid. 
Upon  investigation  it  is  found  that  the  inhaler  leaks  or  that  the 
mouthpiece  does  not  fit,  and  that  the  patient  is  getting  enough  air 
with  the  gas  to  delay  the  anesthesia  indefinitely.  Nitrous  oxid 
is  not  anesthetic  if  atmospheric  air  is  present  in  a  quantity  of  5 
per  cent.  If  any  oxygen  whatever  is  inhaled  with  the  gas,  the 
anesthesia  will  be  delayed  proportionate!}'. 

The  inhaler  should  be  tightly  pressed  to  the  face  so  that  the 
patient  inhales  gas  only,  of  which  the  receptacle  must  be  kept 
full.  The  respirations  will  be  accelerated  and  become  irregular. 
The  pulse,  at  first,  is  generally  exaggerated  in  frequency  and  les- 
sened in  force  on  account  of  excitement,  but  as  the  inhalation 
proceeds  the  heart-beat  rapidly  becomes  strong  and  slow.  The 
peripheral  vasomotors  are  the  first  to  be  stimulated,  and  as  the 
vessels  contract  there  is  a  momentary  blanching  of  the  skin,  a 
diminution  in  vascular  capacity,  a  slight  increase  in  resistance,  and 
a  consequent  increase  in  frequency  of  the  pulse.  The  peripheral 
vasomotors  are  almost  immediately  paralyzed,  resistance  is  les- 
sened, and  the  pulse-frequency  is  greatly  diminished.  By  this 
time  the  heart  itself  is  stimulated  and  for  that  reason  beats  more 
forcibly. 

The  fact  that  arterial  tension  is  only  very  slightly  exaggerated 
makes  the  method  so  far  reasonably  safe.^  Nitrous  oxid  is  not 
in  the  least  dangerous  if  it  is  not  pushed  too  far,  but  the  admin- 
istrator should  know  when  to  stop  it. 

1  I  have  used  it  successfully  upon  two  cases  of  aortic  regurgitation,  one  of  aortic 
stenosis,  six  of  mitral  stenosis,  twelve  of  mitral  regurgitation,  three  with  double  mitral 
lesion,  and  upon  a  large  number  of  elderly  patients  with  hard  arteries. — (B.  F.  Roller.  ) 


6o8        The  Detailed  Technic  of  Gynecic  Surgery 

Consciousness  and  voluntary  motion  are  lost  after  the  first 
few  inhalations,  but  when  the  ether  is  administered  the  patient 
rallies  from  the  gas  before  the  ether  takes  effect.  The  gas 
should  be  pushed  until  three  phenomena  are  observed  :  rapid  and 
irregular  breathing,  spasmodic  movements  of  the  voluntary 
muscles,  and  a  marked  cyanosis. 

H.  C.  Wood  says  nitrous  oxid  anesthesia  is  one  of  asphyxia. 
It  is  more  probably  due  to  a  substitution  of  nitrous  oxid  for  oxy- 
gen in  the  blood,  forming  nitrous  oxid  hemoglobin,  which  is  blue. 
The  suffusion  of  blue  blood  in  the  peripheral  vessels,  on  account 
of  paralysis  of  the  peripheral  vasomotors,  is  responsible  for  the 
cyanosis,  which  is  not,  as  many  think,  an  evidence  of  cardiac 
failure.  Marked  cyanosis  must  occur.  It  generally  appears  in 
about  forty-five  seconds.  It  should  not  be  alarming  and  must 
appear  before  the  anesthesia  is  sufficiently  advanced.  The 
rapid,  irregular  breathing  and  spasmodic  movements  ot  the  vol- 
untary muscles  are  the  signals  that  the  gas  must  soon  be  discon- 
tinued. If  the  gas  is  pushed  further,  the  patient  reaches  the 
acme  of  stimulation,  a  universal  tetanic  spasm.  This  will  be  fol- 
lowed by  paralysis  of  the  heart  and  respiration  centers,  and  the 
patient  will  die  unless  revived  by  artificial  respiration.  There- 
fore, when  rapid  and  irregular  breathing  and  spasmodic  move- 
ments of  the  voluntary  muscles  appear,  providing  the  patient  is 
markedly  cyanotic,  ether  must  be  immediately  substituted  for  the 
gas. 

In  changing  to  ether,  the  simplest  and  most  hygienic  inhaler 
is  clean  gauze  folded  in  forty-eight  to  sixty-four  layers,  five 
by  six  inches.  With  the  gauze  intact  and  unattended,  the 
patient  can  be  moved,  the  larynx  and  nasal  alae  manipulated,  the 
pupils  examined,  the  pulse  watched,  and  the  conjunctivae 
protected  better  and  more  easily  than  with  any  other  inhaler. 
Less  ether  is  required  because  it  can  be  poured  directly  over 
nostrils.  Bronchitis  is  almost  never  produced,  because  the  ether 
is  vaporized  and  well  filtered;  the  patient  does  not  breathe  over 
and  over  the  same  column  of  expired  air,  but  gets  plenty  of 
fresh  air.  For  these  and  other  reasons  the  postanesthetic  shock 
and  nausea  are  very  slight.  Finally,  by  this  method  no  infection 
is  carried  from  one  patient  to  another. 

When  the  moment  arrives  to  discontinue  the  gas,  the 
gauze  should  be  quickly  thrown  across  the  face  and  satu- 
rated over  the  nostrils  with  an  ounce  of  ether.  Ether  is  irri- 
tating, and  its  first  inhalation,  in  addition  to  the  gas  stimulation, 
is  sure  to  be  followed  by  a  spasm  of  the  larynx.  This  may 
be  somewhat  lessened  by  a  preliminary  spray  of  adrenalin 
(l  :  5000)  and   cocain  (i  :  50).      A  better   procedure,  however,  is 


Anesthesia  and   Anesthetics  609 

to  facilitate  breathing,  as  follows :  Hook  the  third  and  fourth 
fingers  of  both  hands  behind  the  rami  of  the  inferior  maxilla  and 
pull  forward;  at  the  same  time,  with  the  first  and  second  fingers 
of  both  hands  roll  the  skin  and  subcutaneous  tissues  up  over  the 
chin,  elevating  the  hyoid  and  opening  the  larynx.  Press  later- 
ally over  the  malar  bones  with  the  thumbs  and  open  the  anterior 
nares.  With  this  manipulation  the  spasm  passes  off  in  a  few 
seconds  and  the  patient  is  etherized  by  the  first  three  or  four  in- 
halations. By  the  time  the  patient  is  lifted  to  the  operating  table 
she  is  completely  relaxed  and  ready  for  operation.  The  whole 
process  up  to  this  point  requires  on  the  average  one  minute  and 
forty-five  seconds. 

Pushing  the  ether  in  this  manner  has  been  objected  to,  but 
it  is  not  in  the  least  dangerous.  It  makes  no  difference  how  fast 
the  ether  is  given  if  it  is  stopped  when  the  patient  is  sufficiently 
anesthetized.  To  determine  this,  however,  requires  a  compre- 
hension of  the  physiological  effects  of  ether.  They  are  repre- 
sented diagrammatically  by  a  curve,  all  bodily  functions  being 
stimulated  increasingly  to  the  acme.  Then  they  are  all  gradually 
depressed,  the  early  stage  of  depression  being  anesthesia  and  its 
termination  paralysis.  Fortunately,  on  account  of  a  difference  in 
susceptibility  of  the  organic  functions,  some  are  affected  earlier 
than  others,  and  this  fact  affords  a  valuable  clinical  guide  to  the 
use  of  ether.  The  height  of  stimulation  once  passed,  the  de- 
pressing effects  follow  in  regular  sequence. 

After  consciousness  is  lost  there  are  four  distinct  stages  of  anes- 
thesia, each  resulting  trom  the  paralysis  of  a  definite  group  of  nerve- 
centers  and  muscles.  When  the  first  group,  which  has  to  do  with 
the  voluntary  muscles,  is  paralyzed,  all  motor  power  is  lost  and  it 
is  impossible  to  evoke  contraction  of  a  voluntary  muscle.  The 
best  indicators  for  this  group  are  the  orbicularis  palpebrarum  and 
recti  muscles  of  the  eye.  Raise  the  upper  lid.  If  the  eyeball 
remains  stationary,  the  recti  are  paralyzed.  Let  the  lid  fall,  and 
if  there  is  no  winking  and  no  elasticity  the  orbicularis  is  anes- 
thetized. When  these  two  are  paralyzed,  all  the  voluntary  mus- 
cles are  under  control  and  the  first  stage  is  complete. 

The  pupillary  muscles  are  the  second  group.  The  pupil  is 
controlled  by  two  involuntary  muscles  of  the  iris,  a  circular 
sphincter,  and  a  radiating  dilator.  The  sphincter  is  stimulated 
first,  and  the  pupil  grows  progressively  smaller,  though  respon- 
sive to  light,  until,  when  the  sphincter  is  paralyzed,  the  radiating 
muscle  suddenly  dilates  the  pupil.  The  dilator  soon  becomes 
paralyzed  also,  but  the  pupil,  of  course,  remains  large  and  sta- 
tionary, and  the  second  stage  is  complete. 

Early  in  the  second  stage,  when  the  pupil  is  partly  contracted, 
39 


6io       The  Detailed  Technic  of  Gynecic  Surgery 

if  ether  is  discontinued,  the  pupil  dilates.  This  is  because  the 
sphincter,  no  longer  stimulated  and  already  overworked,  is  tem- 
porarily weaker  than  the  dilator.  The  beginner  is  at  a  loss  to 
know  whether  the  patient  is  coming  out  of  the  second  or  going 
into  the  third  stage.  If  the  pupil  is  dilated,  expose  it  suddenly 
to  light.  If  it  responds,  she  is  reviving.  If  it  is  dilated  and 
does  not  respond  to  the  light,  she  has  entered  the  third  stage. 

For  all  practical  purposes  the  second  stage  is  the  most 
important.  It  is  in  this  stage  that  the  patient  should  be  kept 
during  major  operations.  Keep  the  pupil  shghtly  contracted,  but 
always  reactive  to  light — /.  e.,  in  the  beginning  of  the  second 
stage.  At  this  point  the  patient  is  just  enough  anesthetized  to 
meet  all  indications,  but  not  far  enough  to  be  in  danger. 

The  third  group  to  be  paralyzed  by  ether  are  the  respiratory 
muscles  and  centers.  If  ether  be  pushed  to  dissolution,  the  res- 
pirations grow  more  and  more  shallow,  abdominal,  and  finally 
cease.  Early  in  this  stage  cyanosis  appears  from  imperfect  aera- 
tion, and  paralysis  of  the  respiration  is  followed  rapidly  by  paral- 
ysis of  the  last  group — the  cardiac  reflexes.  As  they  are  more 
and  more  depressed,  the  pulse  becomes  running  and  thready  and 
suddenly  stops. 

It  appears,  therefore,  that  the  pulse  which  was  formerly  the 
anesthetic  guide  is  of  no  use  to  an  etherizer  except  to  show  how 
the  patient  is  standing  the  hemorrhage  and  operation.  The 
reflexes  are  always  depressed  by  ether  in  the  above  order.  Since 
the  first  and  the  early  part  of  the  second  stage  are  sufficient, 
the  ether  should  not  be  pushed  to  the  third  or  fourth  stage,  for 
it  unnecessarily  endangers  the  patient's  life.  Of  course,  in  pa- 
tients with  diseased  and  unreliable  pupils,  the  respirations  must 
be  used  as  the  safeguard  against  too  deep  anesthesia.  At  the 
\'ery  first  disturbance  of  respiration,  the  ether  should  be  tempo- 
rarily discontinued.  After  the  patient  is  thoroughly  anesthe- 
tized, it  requires  very  little  ether  to  continue  the  anesthesia,  three 
or  four  ounces  being  ordinarily  sufficient  for  any  major  operation. 

Occasionally,  patients,  especially  negroes,  suffer  a  very  an- 
noying accumulation  of  mucus  and  saliva  in  the  mouth  and 
throat  from  ether.  This  does  not  occur  with  chloroform,  and  in 
such  cases  the  anesthesia  can  be  maintained  much  more  com- 
fortably by  chloroform;  but  the  postanesthetic  nausea  which 
a  mixture  of  gas  and  chloroform  produces  is  so  extremely 
annoying  that  its  use  can  not  be  recommended. 

The  choice  of  an  anesthetic  depends  upon  the  conditions  of 
each  case.  Cocain  is  the  best  local  anesthetic,  but  its  use  in 
major  operations  should  be  limited  to  cases  in  which  a  constitu- 
tional anesthetic  is  absolutely  contraindicated. 


The  Technic  of   an  Abdominal   Section 


6ii 


Chloroform  acts  much  like  ether,  but  is  so  much  more 
powerful  that  it  is  considered  treacherous  and  unsafe.  Where 
the  same  anesthetic  is  to  be  used  throughout,  ether  should  be 
preferred,  unless  it  be  in  negroes,  who  are  very  resistant  to 
ether,  but  react  perfectly  to  chloroform.  The  postanesthetic 
nausea,  however,  must  not  be  forgotten.  In  all  major  oper- 
ations where  it  is  at  all  practicable,  not  only  in  hospital  service 
and  busy  clinics,  but  in  private  houses,  the  best  of  all  methods 
is  the  method  by  gas  and  ether  described  above.  The  entire 
method  requires  but  a  minute  and  a  half  to  two  minutes 
to  anesthetize  the  patient  sufficiently  for  major  operations.  It 
requires  but  a  few  inspirations  of  gas  and  three  or  four  ounces 
of  ether,  and  costs  only  about  five  cents  more  per  case.      It  is  not 


Fig.  527- — Cage  removed  from  the  auto- 
clave wrapped  in  its  sheet. 


Fig.  528. — Sheet  draped  over  the  cage 
after  the  lid  is  raised. 


in  the  least  unpleasant  to  the  patient,  and  the  postanesthetic 
effects  are  reduced  to  the  minimum.  It  seems  unquestionably 
the  method  to  be  preferred  in  all  cases  requiring  deep  anesthesia, 
and  has  no  contraindications  where  a  constitutional  anesthetic 
can  be  used  at  all. 

The  Technic  of  an  Abdominal  Section. — Arrangement  of 
Tables  and  Instruments ;  Position  of  Assistants. — Two  tables  are 
required,  one  for  instruments,  one  for  the  pads  and  their  basins  ; 
each  is  covered  with  a  sterile  sheet.  On  another  table  the  cage  of 
the  autoclave  rests.  It  is  so  draped  with  a  sterile  sheet  that  it  is 
always  protected  from  contamination  even  though  the  lid  is 
opened.  Only  the  gloved  hands  of  the  operator  or  his  assistants 
are  inserted  into  it,  a  nurse  raising  the  sheet  over  it  while  the 


6i2       The  Detailed  Technic  of  Gynecic  Surgery 

hand  is  inserted,  and  dropping  it  immediately  the  hand  is  re- 
moved (Figs.  527,  528,  and  529).  Two  sterile  basins  on  stands 
are  placed  back  of  the  operator  and  his  first  assistant.  They  are 
filled  with  sterile  water  to  rinse  the  hands  during  the  operation. 
As  soon  as  the  water  is  used  for  this  purpose,  it  is  changed  by  a 
nurse,  so  that  it  shall  always  be  fi-esh.  The  operator  stands  on 
the  patient's  right  side,  his  first  assistant  on  her  left;  the  second 
assistant  stands  at  her  knees.  Two  nurses  are  on  duty  in  the 
operating  room,  but  they  take  no  part  in  the  operation  itself 
The  author  prefers  to  have  his  first  assistant  manage  the  pads,  so 
as  to  concentrate  responsibility  as  much  as  possible. 


Fig.  529. — The  operator  inserting  his  hand  in  the  autoclave  cage  for  dressings,  etc. 


Securing  the  Patient  on  the  Table Straps  are  provided  on  the 

end  of  the  table  for  the  patient's  legs  just  above  the  ankles. 
Two  pieces  of  gauze  bandage  are  tied  on  the  uprights  at  the 
head  of  the  table,  to  tie  around  the  wrists.  The  arms  are  flexed 
and  the  wrists  are  tied  so  that  they  are  brought  to  a  level  with 
the  shoulders.  They  are  raised  no  higher  for  fear  of  paralysis, 
which  will  occasionally  develop  if  the  arms  are  pulled  forcibly 
above  the  patient's  head  and  are  held  there  during  an  operation. 
This  method  is  preferable  to  pinning  the  arms  by  the  sleeves  of  the 
gown  across  the  patient's  breast,  which  interferes  with  her  respi- 
ration. The  author's  table  is  provided  with  shoulder  supports  to 
keep  the  patient  from  slipping  and  to  ease  the  strain  on  the  knees 
in  the  Trendelenburg  posture,  but  they  are  not  used,  as  they  are 


Preparing-  the  Field  of   Operation 


6i 


not  found  to  be  necessary  and  they  interfere  with  the  air-cushion 
on  which  the  patient's  body  Hes. 


Fig.  530. — Abdominal  binder  turned  back,  exposing  the  dressings. 


^'S-  531- — Abdominal  dressings  turned  down  over  patient's  thighs. 


Preparing  the  Field  of  Operation The  skin  of  the  abdomen  is 

prepared   by  tw^o  cleansings   as  already   described.      When  the 


6i4       The  Detailed  Technic  of  Gynecic  Surgery 

patient  is  secured  on  the  table,  a  nurse  loosens  the  binder  and 
turns  its  tails  back;  she  then  turns  the  abdominal  pad  and  the 
dressings  down  ov^ei-  the  patient's  knees,  by  catching  its  upper 
edge.  The  skin  of  the  abdomen  being  exposed,  the  nurse  pours 
some  sterile  alcohol  (boiled)  from  a  flask  over  the  abdomen ;  the 


Fig.  532. — Rubber-dam  spread  over  abdomen. 


Fig.  533. — 'I'owels  pinned  over  rubber-dam,  leaving  no  skin  surface  exposed. 


first  assistant  rubs  the  line  of  incision  vigorously  with  a  gauze 
pad  for  a  moment  or  two.  A  piece  of  rubber-dam,  18  inches 
square,  sterilized  by  boiling  water,  is  spread  over  the  abdomen, 
covering  the  symphysis  and  reaching  two  or  three  inches  down  the 
thighs.      Murphy's  adhesive  rubber-dam  is  not  satisfactory.      It 


The  Abdominal   Incision 


6i 


is  difficult  or  impossible  to  sterilize,  it  does  not  stick  tight  enough, 
and  at  the  end  of  the  operation  it  is  rumpled  or  torn,  not  sub- 
serving its  purpose  of  completely  concealing  and  protecting  the 
skin.  Gutta-percha  tissue  made  adhesive  by  pouring  a  Httle 
ether  on  the  skin  is  open  to  the  same  objection.  The  principle 
of  protecting  the  patient  from  infection  from  her  own  skin  is  cor- 
rect, and  siiould  be  uniformly  adopted.     The  author's  method 


Fig.  534- — Skin  incision  completed  ;  edges  of  rubber-dam  clamped  to  the  skin  with 

Michel's  clamps. 


of  doing  so  has  been  found  reliable  and  satisfactory  in  all  kinds 
of  abdominal  operations.  Over  the  rubber-dam  a  folded  sterile 
sheet  is  placed,  with  its  upper  edge  just  above  the  symphysis; 
another  one  is  spread  over  the  thorax,  reaching  to  or  below  the 
umbilicus.  A  towel  is  spread  over  each  sheet  and  tucked  under 
the  edge;  two  towels  are  laid  over  the  flanks;  the  four  towels 
are  pinned  together  with  sterile  safety  pins. 

The  Abdomina!  Incision A   slit  is   made   in  the  rubber-dam 


6i6 


The  Detailed  Technic  of  Gynecic  Surgery 


with  scissors,  corresponding  in  length  and  position  with  the  skin 
incision.  To  slit  the  rubber  neatly  it  should  be  thrown  into  a 
transverse  fold  just  above  the  symphysis,  by  the  operator  and 
his  assistant  seizing  it  between  the  thumb  and  forefinger. 
The  skin  is  incised  and  the  fat  is  cut  to  the  deep  fascia ; 
then  the  edges  of  the  rubber-dam  are  fastened  to  the  edges 
of  the   skin   with    Michel's    clamps,    clamped   tight,  the   rubber 


Fig.  535. — Splitting  the  rectus  muscle.  Fig.  536. — Incising  the  peritoneum. 


overlapping  the  skin  edges.  Two  or  three  clamps  are  needed 
on  each  side.  No  matter  how  long  the  operation  lasts,  or  how 
much  manipulation  is  required,  including  the  use  of  retractors, 
the  rubber-dam  keeps  its  place  at  the  end  of  the  operation,  and 
no  skin  surface  whatever  is  exposed  for  ligatures  to  trail  over  or 
to  infect  the  gloves,  pads,  and  instruments,  or  coils  of  intestines 
that  sometimes  must  be  turned  out  of  the  wound  and  laid  upon 
the  abdomen.      The  skin  around  the  wound  being  thus  covered, 


The  Trendelenburg-  Posture 


617 


the  fascia  is  cut  with  a  sharp  knife  by  a  light  stroke.  The  rectus 
muscle  which  conies  into  view  is  split  with  the  forefingers.  The 
peritoneum  is  picked  up  by  the  points  of  two  hemostats  and  is 
cut  between  them.  A  short  nick  only  is  made.  As  the  atmos- 
pheric pressure  is  felt  by  the  intestines  they  drop  back  out  of  the 
way.  The  incision  is  lengthened  in  the  peritoneum  with  scissors 
to  the  full  length  of  the  wound. 

Packing  the  Abdominal  Cavity  with  Pads. — If  there  is  pus  or 
putrescible  liquid  in  the  pelvis,  the  patient  is  raised  in  the  Tren- 
delenburg   posture    and    five    to  eight   pads  are   packed  in  the 


Fig.  537- — -Abdominal  incision  completed. 


abdominal  cavity,  above  and  to  both  sides  of  the  pelvic  brim,  so 
as  to  isolate  the  pelvic  cavity  and  to  keep  back  the  intestines. 

The  Trendelenburg  posture  is  essential  in  many  pelvic  and  ab- 
dominal operations,  but  it  should  be  utilized  only  so  long  as  it  is 
absolutely  necessary.  The  strain  on  the  circulatory  and  respira- 
tory apparatus  is  much  increased  by  keeping  the  trunk  inclined 
at  an  angle  of  45  degrees  or  more,  and  serious  harm  may  result 
from  the  careless  practice  of  raising  a  patient  in  the  Trendelen- 
burg posture  at  the  beginning  of  an  operation  and  keeping  her 
there  until  it  is  finished,  when  many  of  the  steps  could  just  as  well 
be  carried  out  in  the  horizontal  position. 


6i8       The  Detailed  Technic  of  Gynecic  Surgery 

The  Methods  of  Securing  the  Blood= vessels  of  the  Broad  Liga= 

ments  and   the  Treatment   of    the  Stump An    operator    should 

be  thoroughly  familiar  with  all  the  methods  of  treating  the  stump 
in  salpingo-oophorectomy  and  in  the  removal  of  pelvic  and  ab- 
dom.inal  tumors.      Each  one  has  its  merits  and  its  place. 

TIic  Mass  Ligature. — The  broad  ligament  is  perforated  to  the 


> 


'^"-^y 


Fig.  538. — The  mass  ligature  of  the  broad  ligament. 


Fig.  539. — The  mass  ligature  tied  and  the  long  ends  doubled  back. 


median  side  of  the  round  ligament,  with  a  pedicle  needle  armed 
with  a  double  ligature,  both  ends  equally  long.  A  forefinger  is 
hooked  through  the  loop ;  the  needle  is  withdrawn ;  the  loop  of 
the  ligature  is  cut ;  one  end  is  tied  around  the  tube  as  close  on 
the  uterine  cornu  as  possible  with  a  surgeon's  knot  first  and  a 
single  knot  on  top  of  it ;  the  other  is  tied  under  the  ovary  around 


Ligation  of  Arteries 


619 


the  free  edge  of  the  broad  hgament;  the  end  away  from  the 
operator  is  left  long,  is  doubled  back  around  the  stump,  beneath 
the  puncture  point  of  the  pedicle  needle,  and  is  tied  securely 
around  the  whole  stump,  just  under  the  two  halves  of  the  dou- 
ble ligature.  The  mass  ligature  is  quickly  applied,  and  gives  the 
greatest  security  against  hemorrhage,  but  is  not  suitable  for  a 
thick,  infiltrated  Hgament  nor  for  septic  cases.  The  Staffordshire 
knot,  recommended  by  Tait  and  others,  is  quickly  tied,  but  does 
not  secure  the  puncture  point  in  the  broad  ligament. 


Fig.  540. — Ligatures  securing  the  ovarian  and  uterine  arteries. 


Fig.  541. — Ligatures  securing  the  three  arteries  of  the  broad  ligament. 


The  Separate  Ligation  of  the  Arteries  of  the  Broad  Ligament. 
— There  are  a  number  of  ways  to  secure  the  arteries  of  the 
broad  ligament  separately.  A  ligature  threaded  on  a  pedicle  or 
an  ordinary  curved  needle  may  be  passed  under  the  tube  and 
ovarian  ligament  and  tied  over  the  tube  on  the  uterine  cornu  ; 
another  ligature  is  passed  through  the  outer  edge  of  the  broad 
ligament  far  enough  in  the  median  direction  to  secure  the  ovarian 
artery,  or  around  the  inner  side  of  the  round  ligament  to  secure 
its  artery  as  well  as  the  ovarian.      This  ligature  is  placed  below 


620       The  Detailed  Technic  of  Gynecic  Surgery 

or  above  the  ovary  as  it  is  intended  to  remove  or  to  leave  it. 
Another  plan  is  to  place  three  ligatures  in  the  broad  ligament 
securing  the  uterine,  the  ovarian,  and  the  round-ligament  artery 
(Fig.  541),  and  then  cutting  off  the  top  of  the  broad  ligament 
with  the  tube  and  ovary.  A  wedge-shaped  exsection  of  the 
uterine  end  of  the  tube  may  be  made  by  this  plan  if  desired. 
Another  plan  is  to   clamp  the   ovarian  artery,  to   cut  the  broad 


Fig.  542. — Ligatures  tied  ;   tube  and  ovary  removed  with  wedge-shaped  exsection  of 

uterine  cornu. 


Fig.  543. — Tube  and  ovary  removed  on  left  side  ;   hgatures  applied  for  the  removal 
of  the  tube  alone  on  the  right  side. 


ligament  medianward,  and  to  clamp  the  arteries  as  they  are  cut, 
tying  them  separately  after  the  tube  is  removed,  as  an  artery  is 
ligated  elsewhere  in  the  body.  Still  another  plan  is  to  split  the 
peritoneum  over  the  top  of  the  tube  with  a  sharp  knife;  to  cut 
the  uterine  end  of  the  tube  across  at  the  cornu,  and  to  strip  the 
tube  out  of  its  bed  in  the  mesosalpinx;  the  isthmus  can  be  pulled 
free;  it  is  necessary  to  cut  the  mesosalpinx  of  the  ampulla,  but 
the  scissors  can  be  kept  so  close  to  the  under  side  of  the  tube  that 


Lieation  of  Arteries 


621 


only  the  small  tubal  branches  of  the  utero-ovarian  artery  are 
severed  and  the  bleeding  is  not  profuse.  The  small  arteries 
should  be  tied  separately  with  fine  catgut  or  silk. 

In  all  the  methods  leaving  a  raw  surface  along  the  top  of  the 
broad  ligament,  the  anterior  and  posterior  layer  of  its  peritoneum 
should  be  joined  with  a  continuous  suture  of  catgut. 


Fig.  544. — Tube  and  ovary  removed  from  one  side  ;  tube  alone  from  the  other. 


Fig.  545. — Tube  and  ovary  removed  from  one  side  ;   tube  exsected  on  the  other  and 
ovary  transplanted  in  uterine  cornu. 


If  it  is  desirable  or  necessary  to  remove  the  ovary  separate!}', 
a  mass  ligature  is  placed  around  the  mesovarium,  by  a  pedicle 
needle  which  pierces  its  middle,  the  ovary  being  pulled  away  from 
the  broad  ligament  to  make  as  good  a  pedicle  as  possible.  If  the 
pedicle  of  a  tumor,  as  an  ovarian  cyst,  is  very  broad ;  it  the  broad 


62  2        The  Detailed  Technic  of  Gynecic  Surgery 

ligament  is  much  increased  in  transverse  length  from  any  cause  or 
is  very  vascular,  a  chain  Hgature  may  be  required.  This  ligature 
is  most  often  required  by  a  pedunculated  ovarian  cyst  or  some- 
times by  a  broad  ligament  cyst  (Fig.  549). 

Downes'  electrothermic  hemostatic  clamps  are  an  indispen- 
sable part  of  a  good  equipment  for  abdominal  and  pelvic  surgery. 


) 


Fig.  546. — Splitting  the  peritoneum  over  the  tube  (diagrammatic). 


Fig.  547. — Removing  the  tube  by  dividing  the  mesosalpinx. 


I  have  used  them  in  hysterectomies  for  sarcoma  and  cancer  ; 
for  tubal  pregnancies  ;  for  all  varieties  of  tubo-ovarian  inflam- 
mations ;  for  an  ovarian  cyst  twisted  on  its  pedicle,  and  other 
neoplasms  with  a  slender  or  thin,  flat  pedicle  ;  in  all  about  fifty 
times.  In  two  cases  of  extra-uterine  pregnancy  the  arteries  of 
the  thickened  broad  ligament  spurted  through  the  stump  and  re- 
quired ligatures.     In  none  of  the  other  cases  was  there  any  pri- 


Electrothermic  Hemostasis 


62 


mary  or  secondary  bleeding.      I   am  not  willing  to  try  them  for 
appendectomy  on  account  of  the   risk  of  scorching  the  wall   of 
the  colon  ;  nor  would  I  use  them  for  a  thick,  vascular  pedicle. 
The  clamps  and  cable  are  boiled  with  the  instruments  and 


Fig.  548. — Ligation  of  the  mesovarium. 


Fig.  549. — Inserting  a  chain  ligature  in  the  broad  ligament. 


the  transformer  is  placed  in  convenient  position,  connected  with 
the  current,  for  every  abdominal  operation,  so  that  the  apparatus 
may  be  used  if  the  case  is  suitable  for  it. 

In  applying  the  clamp,  the  inner  surface  of  the  blade  is  wiped 
with   sterile  oil  ;    the   clamp   is   fastened  with   the   lever  on  the 


624       The  Detailed  Technic  of  Gynecic  Surgery 

handle  in  such  a  way  that  none  of  the  stump  ghdes  out  of  its 
grip  at  the  tips  of  the  blades.  The  protector  is  fastened  under  the 
clamp.  The  cable  is  connected  ;  the  current  is  turned  on  till  the 
amperemeter  registers  60;  it  is  left  on  thirty  seconds,  the  tissues 


^^S-  550- — I  he  loops  of  the  chain  ligature  are  cut,  the  ends  intertwined  and  tied. 


'^'g-  551- — The  cable  attached  to  the  transformer  is  secured  by  a  safety  pin  under  an 

extra  sterile  towel. 


after  ten  to  fifteen  seconds  bubbling  with  heat  in  its  grasp.  Tlie 
current  is  turned  off.  The  clamp  remains  undisturbed  another  thirty 
seconds.  The  tissue  to  be  cut  away  is  shaved  off  the  upper  sur- 
face of  the  clamp  with  a  sharp  knife.  The  clamp  is  loosened 
by  throwing  back  the  lever  on  its  handle  ;  it  is  gently  withdrawn, 


Electrothermic   Hemostasis 


625 


with  its  blades  opened  as  far  as  the  protector  permits  ;  the  pro- 
tector is  unfastened  and  removed  ;  the  stump,  as  thin  as  a  ribbon 
and  as  white  as  paper,  is  allowed  to  drop  and  must  not  be  dis- 


Fig.  552. — The  clamp  is  applied  to  the  broad  ligament  under  the  tube  and  ovary; 
the  protector  is  fastened  under  it. 


Fig.  553- — -The  clamp  is  applied  under  the  tube  and  above  the  ovary  for  the  removal 

of  the  former  alone. 


turbed  with  pads,  instruments,  handling,  or  traction.  It  must  be 
carefully  observed,  however;  for  bleeding.  If  it  does  not  bleed 
in  the  course  of  two  or  three  minutes,  secondary  hemorrhage 
need  not  be  feared.  This  statement  is  based  on  the  experience 
40 


626       The  Detailed  Technic  of  Gynecic  Surgery 

of  Downes,  myself,  and  a  number  of  others.  I  know  of  no  case 
of  secondary  hemorrhage  so  far  and  feel  perfectly  secure  in  its 
use  in  favorable  cases. 

TJic  angiotribc,  which  is  intended  to  afford  hemostasis  by 
crushing  the  blood-vessels  in  the  broad  ligament  with  great 
force,  is  simply  mentioned  to  be  unreservedly  condemned.  The 
number  of  deaths  from  secondary  hemorrhage  after  its  use  make 
its  emplo}'mcnt  unjustifiable. 

The  Choice  of  Catgut  or  Silk  for  Suture  and  Ligature  Material. — 
The  author's  experience  extends  over  the  time  when  nothing  but 
silk  was  used  for  ligature  material,  over  the  period  of  reaction 
against  silk  and  the  exclusive  use  of  catgut,  to  the  present  com- 
mon-sense practice  of  using  silk  as  a  ligature  material  in  all  per- 
fectly clean  cases,  without  drainage  and  with  no  chance  of  oozing, 
the  formation  of  a  hematocele,  and  the  necessity  for  a  puncture 


Fig.  554. — The  stamps  left  after  the  removal  of  the  appendages  by  Dowries'  clamps. 

of  the  vaginal  vault.  Catgut  at  best  is  sometimes  treacherous : 
the  knot  may  slip,  the  gut  break  or  absorb  too  soon,  with  a  fatal 
secondary  hemorrhage  as  the  result.  This  risk  is  remote  and 
must  be  taken  in  all  infections,  inflammatory  conditions,  and  if 
there  is  some  oozing  which  is  not  completely  controlled.  Cumol 
catgut  is  used  exclusively  for  ligature  material  on  account  of 
its  tensile  strength  and  rapid  absorption.  The  suture  material 
is  formalin  gut,  prepared  as  described  (p.  595),  with  a  durability 
of  two  to  four  weeks. 

The  Examination  of   the   Appendix After   the    abdominal    or 

pelvic  operation  is  finished,^  the  vermiform  appendix  should 
always  be  examined,  by  retracting  the  right  side  of  the  wound 
with  an  abdominal  retractor  and  lifting  the  caput  coli  out  of  the 

Mn  a  suspension  of  the  uterus  the  appendix  must  be  examined  before  the  sus- 
pension stitches  are  tied. 


The  Examination  of   the  Appendix 


627 


wound.  The  latter  is  easily  recognized  by  its  white  color  and 
the  longitudinal  fibrous  bands  in  it.  In  10  per  cent,  or  more  of 
all  abdominal  sections  the  gynecic  surgeon  finds  an  indication 
for  the  removal  of  the  appendix,  in  adhesions,  distention,  injection, 


Fig.  555. — Ligating  the  mesappendix. 


Fig.  556. — Cutting  the  mesappen- 
dix and  inserting  the  purse-string  suture 
around  the  base  of  the  appendix. 


Fig.  557- — The  appendix  is  amputated. 


Fig.  558. — The  stump  of  the  appendix 
is  inverted. 


or  infiltration.  The  mesappendix  is  ligated  and  cut;  a  purse- 
string  suture  of  catgut  is  inserted  around  the  base  of  the  appendix; 
it  is  cut  off;  its  stump,  at  least  a  quarter-  of  an  inch  long,  is 
inverted  with  tissue  forceps;  the  scissors  and  tissue  forceps  used 
to  cut  and  invert  the  appendix  are  dropped  on  the  floor;  the 


628       The  Detailed  Technic  of  Gynecic  Surgery 

purse-string  suture  is  pulled  tight  and  tied.      A  mattress  suture 
unites  the  peritoneum  over  the  site  of  the  stump. 

The  Toilet  of  the  Peritoneum, — At  the  conclusion  of  the  opera- 
tion there  should  be  a  careful  inspection  of  the  whole  field  for 


Fig.  559. — A  mattress  suture  covers  the  site  of  the  inverted  stump  of  the  appendix. 


Fig.  560. — Apparatus  for  douching  the  abdominal  cavity. 

oozing  or  hemorrhage ;  raw  surfaces  should  be  covered  by  join- 
ing peritoneal  edges  over  them,  if  possible.  All  blood  and  dis- 
charges should  be  carefully  cleaned  out  with  dry  pads,  especially 
from  Douglas's  pouch,  the  vesico-uterine  pouch,  and  the  kidney 
pouches. 


The  Toilet  of   the  Peritoneum 


629 


The  practice  of  douching  the  abdomen  and  of  pouring  normal 
salt  solution  into  it  to  remain  is  not  so  efficient  as  the  dry  cleansing, 
is  an  unnecessary  waste  of  time,  wets  the  patient,  predisposes  her  to 
cold,  and  is  not  in  accord  with  good  surgical  principles  in  general. 
The  only  condition  in  which  douching  the  abdominal  cavity  is  of 
service  is  for  the  hemorrhage  of  a  ruptured  tubal  gestation  or  a 


Fig.  561. — The  peritoneum  united  by  a 
continuous  suture. 


Fig.  562. — The  fascia  united  by  a 
continuous  suture  and  further  secured  by 
three  mattress  sutures. 


tubal  abortion.  It  is  the  quickest  way  to  remove  clots  and  liquid 
blood  from  all  the  nooks  and  crannies  of  the  whole  abdominal 
cavity.  Gallons  of  hot  sterile  water  are  required  (110°  F.). 
Normal  salt  solution  is  unnecessary.  The  water  is  poured  in 
a  glass  funnel  held  at  arm's  length  above  the  abdomen.  A  metal 
irrigating  tube  is  attached  to  the  rubber  tubing  of  the  funnel. 


630 


The  Detailed  Technic  of  Gynecic  Surgery 


The  Closure  of  the  Abdominal  Wound. — The  peritoneum  is 
united  with  a  running  suture  of  formalin  gut  (No.  i);  two  or 
three  mattress  sutures  (formalin  gut,  No.  3)  are  inserted  in  the 
fascia;  the  fascia  is  united  with  a  continuous  suture  (formalin  gut, 
No.  3);  the  mattress  sutures  are  tied;  the  rubber-dam  is  re- 
moved ;  the  fat  and  superficial  fascia  are  united  with  a  tier  suture 
(formalin   gut,  No.  00  to   No.  i),  in  two   tiers,  with  the  single 


Fig.  563. — The  fat  and  superficial 
fascia  united  by  a  double  tier  continuous 
suture. 


Fig.  564. — The  insertion  of  the  subcu- 
ticular stitch  in  the  skin. 


knot  in  the  upper  angle  of  the  wound.  The  skin  is  united  with 
an  intracutaneous,  subcuticular  stitch,  or,  if  the  wound  is  long  and 
economy  of  time  is  essential,  with  a  running  suture.  The  suture 
is  formalin  gut.  No.  i,  threaded  on  a  long,  straight,  spear-pointed 
needle  not  requiring  a  needle-holder.  The  skin  above  each 
needle  puncture  is  held  together  with  the  forceps  that  are  pro- 
vided in  the  Michel  clamp  outfit.  For  the  intracutaneous  stitch 
the- author  finds  Emmet's  cervical  needle  the  most  convenient. 


Dressino-  the  Wound 


631 


Dressing  the  Wound. — The  skin  of  the  abdomen  is  carefully 
cleansed  with  sublimate  solution,  i  :  2000,  poured  over  it  out  of 
a  pitcher  and  dried  with  a  sterile  towel.  A  sheet  of  silver  foil  is 
laid  over  the  wound;  a  sheet  of  the  paper  from  the  book  of  foil 
is  laid  over  the  foil ;  alcohol  is  poured  on  it  to  make  it  adhere 
to  the  skin.      Squares  of  gauze  are  placed  over  the  lower  abdo- 


Fig.  565. — The  subcuticular  stitch  inserted  and  its  ends  knotted. 


men,  and  the  dressing-  is  held  in  place  by  strips  of  zinc  oxid 
plaster.  A  many-tailed  soft  flannel  binder  is  laid  on  the  wheeled 
stretcher;  the  woman  is  lifted  from  the  operating  table,  laid  on 
the  stretcher  so  that  the'  binder  is  under  the  loins.  As  she  is 
lifted  from  the  table  to  the  stretcher  a  nurse  cleanses  her  back. 
The  binder  is  folded  over  the  abdomen  and  is  then  pinned  tight, 


6^2        The  Detailed  Technic  of  Gynecic  Surgery 


(1 ' 

\ 

/'  ~  TlBf      y ' 

il 

^ 

\\    H 

(7    A 

1       / 

/  ^ 

i 

^ 

\ 

X. 

'\J 

> 

-4^ 

^c^ 

-/ 

r 

Fig.  566. — Inserting  a  continuous  suture  in  the  skin. 


Fig.  567. — Michel's  clamps  and  forceps. 


Drainag-e 


633 


from  above  downward,  with  three  rows  of  safety  pins,  one  in  the 
middle  and  one  on  each  side. 

Drainage. — The  vexed  question  of  drainage  is  practically  set- 
tled. It  is  avoided  if  possible,  but  occasionally  the  patient's  life 
depends  upon  it.  In  all  active  suppurative  processes,  except 
those  of  gonorrhea  and  those  that  are  strictly  localized,  as  an 
ovarian  abscess ;  in  infectious  infiltration  of  the  pelvic  connective 
tissue,  especially  in  streptococcic  infection ;  in  the  case  of  a  dis- 
eased ulcerative  condition  of  the  bowel-wall  ;  if  there  is  per- 
sistent oozing  which  can  not  be  checked,  and  if  the  ureters  are 
injured,    drainage    is    required.       The    constant    demands    upon 


Fig.  568. — Zinc  oxid  plaster  adhesive  strips  applied. 


the  author  for  the  operative  treatment  of  grave  puerperal  in- 
fections have  made  the  question  of  the  best  form  of  drainage  a 
very  anxious  one.  After  more  or  less  disappointing  trials  of 
various  forms  of  drainage,  the  following  plan  has  been  uniformly 
followed  for  the  last  seven  or  eight  years :  A  glass  tube  is  placed 
in  Douglas's  pouch  resting  against  the  back  wall  of  the  uterus; 
a  piece  of  sterile  cotton  plugs  the  mouth  of  the  tube  until  the  tube 
is  covered  with  gauze  ;  the  whole  pelvis  is  filled  with  a  gauze  strip, 
6  inches  wide,  the  end  of  which  emerges  from  the  wound  just  above 
the  drainage-tube.  ^      The  wound  is  as  carefully  closed,  layer  by 

1  At  first  I  used  a  glass  tube  alone  ;   then  gauze  alone  ;   neither  was  satisfactory. 
The  intestines  come  in  too  close  relationship  with  the  tube,  adhere  around  it  and 


634       The  Detailed  Technic  of  Gynecic  Surgery 

layer,  as  though  drainage  had  not  been  employed;  the  skin  just 
above  and  below  the  drainage-tube  and  gauze  strip  is  fastened 
together  with  one  Michel's  clamp. ^  One  or  two  silkworm-gut 
sutures  are  inserted  through  the  skin,  fascia,  and  rectus  muscle, 
but  not  through  the  peritoneum,  to  take  the  strain  off  the  catgut 
sutures.  The  wound  above  and  below  the  tube  is  covered  Avith 
silver  foil.  The  tube  is  sucked  out  by  rubber  tubing  slipped 
within  it,  attached  to  a  two-ounce  hard-rubber  piston  syringe. 


Fig.  569. — Drainage  by  tube  and  gauze. 

The  gauze  squares  are  slit  so  as  to  surround  the  tube  projecting 
above  the  surface   of  the   abdomen.      When    the  flange    of  the 

may  be  injured  by  it  ;  but  of  the  two,  the  tube  is  better  than  the  gauze.  If  a  strip 
of  gauze  is  packed  in  the  pelvis  and  pulled  out  at  the  end  of  twenty-four  or  forty- 
eight  hours,  the  discharges  with  which  it  is  soaked  drip  back  into  Douglas's  pouch, 
making  a  puddle  of  putrescible  or  infected  fluid.  I  once  saw  a  patient  die  in  conse- 
quence. By  using  the  tube  and  gauze  together  the  disadvantages  of  each  are  avoided 
and  it  is  possible  to  save  a  virulently  streptococcic  infected  pelvis  by  this  kind  of 
drainage  that  would  be  hopeless  without  it.  Even  if  the  gauze  is  simply  used  to 
pack  the  pelvis  and  to  check  oozing,  the  tube  should  be  added  for  the  reason  stated, 
that  Ijlood  will  drip  back  in  the  pelvis  when  the  gauze  is  removed. 

^  These  clamps  are  designed  for  the  rapid  closure  of  skin  wounds.  They  are 
not  so  quick  nor  so  satisfactory  as  the  continuous  suture,  but  they  have  their  uses. 
The  self-feeding  forceps  made  in  Germany  by  Leiter  is  very  ingenious,  but  it  often 
fails  to  work. 


Drainage 


635 


tube  must  be  elex'ated  a  little  to  accommodate  the  last  squares 
of  folded  gauze,  other  squares  are  placed  over  its  orifice.  The 
strips  of  zinc  oxid  plaster  and  the  binder  close  the  wound,  which 
is  not  opened  for  twenty-four   hours.      Then,  with   all  the  pre- 


Fig.  570. — The,  mouth  of  the  drainage-tube  is  stoppered  with  cotton  till  it  is  covered 

with  sterile  gauze. 


Fig.  571. — Drainage-tubes  and  syringe  for  sucking  them  out. 


cautions  required  for  the  original  operation,  the  dressings  are 
removed ;  the  glass  tube  is  again  sucked  out  by  a  rubber  tubing 
slipped  down  to  the  bottom  of  Douglas's  pouch  and  attached 
to  a  two-ounce  hard-rubber  piston  syringe.  The  wound  is  then 
closed   as   before,  except   that  yellow  surgical  adhesive  plaster, 


636  The  Detailed  Technic  of  Gynecic  Surgery- 
heated,  is  substituted  for  the  zinc  oxid  plaster.  At  the  end  of 
another  twenty-four  hours  the  wound  is  again  exposed;  the  glass 
tube  sucked  out  as  before ;  the  gauze  strip  is  pulled  out  with  the 
fingers  and  tissue  forceps,  while  an  assistant  holds  his  finger  over 
the  top  of  the  glass  tube  to  prevent  its  coming  out;  the  glass 
tube  is  again  sucked  out;  a  rubber  drainage-tube  is  slipped  in- 
side the  glass  tube;  the  glass  tube  is  pulled  out  while  a  delicate 
long-bladed  drainage  forceps  holds  the  rubber  tube  and  prevents 
the  glass  tube  pulling  it  out ;  a  safety  pin  is  fastened  to  the  rubber 
tube;  the  wound  is  dressed  again.  The  next  day  the  dressings 
are  removed ;  the  bed  is  tilted  up   on  one  side ;  a  Kelly  pad  is 


Fig.    572. — Drainage-tube  and  gauze  in  the  pelvis;   wound  closed,   with  Michel's 
clamps  next  the  tube  and  below  and  above  a  continuous  suture. 


slipped  under  the  patient's  waist;  a  straight-tipped  medicine 
dropper  is  attached  to  the  tube  of  a  fountain  syringe,  is  inserted 
in  the  rubber  drainage-tube,  and  a  quart  or  more  of  sterile 
water  is  allowed  to  flow  through  the  pelvis  and  out  alongside 
the  drainage-tube.  The  irrigation  is  repeated  daily  for  about  ten 
days.  After  a  week  the  tube  is  shortened  every  day  by  cutting  a 
piece  off  the  top  until  it  is  removed.  //  must  not  be  taken  ont, 
for  it  is  usually  impossible  to  get  it  back  again.  The  original 
silver  foil  protects  the  wound  and  is  not  removed  unless  it  is  dis- 
placed or  torn,  when  it  is  replaced.  It  is  often  surprising  to  see 
what  nice-looking  wounds  can  be  secured  in  spite  of  drainage. 
The  Michel  clamps  are  removed  by  the  little  hooklets  that  come 


Drainage 


^Z7 


with  them,  at  the  end  of  a  week,  and  at  the  same  time  the  silk- 
worm-gut sutures  are  removed. 

If  the  area  to  be  drained  after  an  abdominal  section  is  con- 
fined to  Douglas's  pouch  below  the  uterosacral  ligaments,  drain- 
age through  the  vaginal  vault  is  occasionally  preferable  to  the 
abdominal  drainage.  An  assistant  passes  the  first  two  fingers  of 
one  hand  into  the  vagina  and  places  their  tips  firmly  against  the 
posterior  vaginal  vault,  separating  them  a  trifle.  The  operator 
plunges   the  points    of    a  long-handled,   sharp-pointed   scissors, 


Fig.  573. — Sacking  out  \\\e  drainage-tube. 


curved  on  the  flat,  through  the  bottom  of  Douglas's  pouch,  into 
the  vaginal  vault,  between  the  assistant's  finger-tips,  and  with- 
draws them  open,  to  enlarge  the  opening.  The  end  of  a  six- 
inch-wide  gauze  bandage  is  seized  in  a  long,  heavy  Pean  forceps 
and  is  passed  into  the  vagina,  where  it  is  seized  by  the  assistant 
and  pulled  out  of  the  vulva,  after  the  forceps  release  their  grip  on 
it.  The  rest  of  the  gauze  strip,  or  enough  of  it  to  fill  Douglas's 
pouch  to  and  beyond  the  uterosacral  ligaments,  is  packed  in  the 
pelvis.      The    assistant    changes    his    gloves.      The   end    of  the 


638       The  Detailed  Technic  of  Gynecic  Surgery- 
gauze  strip  protruding  from  the  vulva  is  cut  off  when  the  opera- 
tion  is    concluded,  and   a  fresh   strip  of  gauze  is  packed  in  the 
vagina.      The  vaginal  and  pelvic  packings  are  removed  at  the 


Fig.  574. — Silver  foil  above  and  below  the  drainage-tube. 


Fig.  575. — Gauze  squares,  slit  part  way  through  the  middle,  surrounding  the  tube. 


end  of  forty-eight  hours;  the  latter  is  replaced  by  a  T-shaped 
rubber  tube  inserted  into  Douglas's  pouch.  A  fresh  strip  of 
gauze  is  packed  in  the  vagina.  On  and  after  the  conclusion  of 
the  third  day  .sterile  water  is  injected  daily  into  the  drainage-tube 


Drainaoe 


639 


and  consequent!}'  into  Douglas's  pouch;   it  returns  alongside  the 
tube  into  the  vagina. 

Following  the  adage  of  to-day, — "  When  in  doubt  do  not 
drain," — there  is  occasionally  an  accumulation  of  serum  or  blood 
in  Douglas's  pouch  after  an  abdominal  section  which  may  be- 
come infected.      The  symptoms  on  vaginal  examination  are  dis- 


I^'g    576. — Drainage-tube  forceps. 


Fig.  577. — T-shaped  rubber  drain. 


Fig.  578. — T  rubber  drain  seized  in  grip' 
of  dressing  forceps. 


tinctive.  Behind  the  uterus  there  is  a  sensitive  mass,  evidently 
localized,  with  an  indistinct  cystic  or  doughy  feel.  The  tem- 
perature is  elevated,  the  pulse  is  accelerated,  the  patient  com- 
plains of  pelvic  pain  and  discomfort,  the  bowels  are  irritable  or 
there  is  obstinate  constipation,  and  the  abdomen  is  somewhat 
distended.  The  condition  is  quickly  and  effectually  relieved  by 
puncturing  the  vaginal  vault  with   long-handled,   sharp-pointed 


640       The  Detailed  Technic  of  Gynecic  Surgery 

scissors  curved  on  the  flat,  washing  out  the  pelvic  cavity  with 
sterile  water  through  a  Fritsch-Bozeman  two-way  catheter,  and 
inserting  a  T-drain  through  which  Douglas's  pouch  is  irrigated 
daily.  The  tube  is  removed  when  the  discharge  ceases,  the 
water  comes  back  clear,  and  the  local  and  systemic  symptoms 
disappear — in  about  ten  days. 

The  Technic  of  a  Vaginal  Section. — The  vagina  is  distended 
with  retractors,  an  anterior,  short-bladed,  a  posterior,  and  two 
lateral  retractors  with  narrow  blades.  Most  room  is  gained  by 
an  anterior  colpotomy,  which  also  renders  the  uterus  and  its 
appendages  more  accessible.  It  is,  accordingly,  the  operation 
usually  selected.  The  peritoneal  cavity  may  be  opened  through 
the  anterior  vaginal  wall  in  one  of  three  ways  :  by  a  transverse 
incision  in  the  anterior  vaginal  vault  encircling  the  cervix 
(Diihrssen) ;  by  a  median  longitudinal  incision  in  the  anterior 
vaginal  wall  from  the  vaginal  portion  of  the  cervix  an  inch  and 
a  half  downward  (Orthmann) ;  and  by  a  T-shaped  incision,  the 
transverse  bar  encircling  the  cervix  and  extending  for  about 
three-fourths  of  an  inch  to  both  sides  of  the  median  hne,  the 
longitudinal  incision  being  about  an  inch  and  a  half  long  (Mack- 
enrodt,  Webster).  The  last  is  much  the  best  of  the  three.  The 
patient  is  arranged  on  the  table  in  the  dorsal  position  as  for  any 
vaginal  operation.  The  cervix  is  dissected  free  from  the  bladder 
and  the  upper  portion  of  the  vaginal  wall  is  likewise  separated 
from  the  bladder,  which  is  pushed  upward  and  forward  ;  the 
vesico-uterine  reduplication  of  peritoneum  is  opened  ;  the  ap- 
pendages are  hooked  down  and  delivered  through  the  wound, 
and  the  uterus  is  made  accessible  by  exaggeratedly  anteverting 
it.  Landau's  ecarteurs  (p.  247)  are  a  great  convenience  at  this 
stage  of  the  operation.  The  uterus  and  its  appendages  may  be 
made  more  accessible  by  uniting  a  posterior  colpotomy  (a  trans- 
verse incision  through  the  posterior  vaginal  vault  into  Douglas's 
pouch,  an  inch  or  more  long)  with  the  anterior  colpotomy  ;  ligat- 
ing  both  uterine  arteries  and  cutting  the  bases  of  the  broad  liga- 
ment free  from  the  uterus  on  the  median  side  of  the  ligatures. 

Posterior  colpotomy  alone  is  usually  reserved  for  an  explora- 
tion of  the  pelvic  organs  ;  for  the  evacuation  of  an  abscess  in 
Douglas's  pouch  or  on  the  posterior  aspect  of  the  broad  liga- 
ment ;  for  the  removal  of  an  infected  gestation  sac  posterior  to 
the  uterus  ;  for  the  excision  of  a  myoma  in  the  lower  posterior 
uterine  wall ;  and  for  drainage  of  the  pelvic  cavity.  The  wounds 
in  both  vaults  and  the  anterior  vaginal  wall  are  closed  with  in- 
terrupted close-set  sutures  of  silkworm-gut,  shotted,  which  are 
removed  in  two  weeks.  If  necessary,  drainage  may  be  provided 
by  a  strip  of  gauze  between  two   sutures,  which   is   removed  in 


The  Technic  of  a  Vaginal  Section 


641 


forty-eight  hours.      If  necessary  to   continue  the  irrigation   and 
drainage  of  the  pelvis  for  some  days  (as  in  a  suppurating  cavity, 


,U- 

^^^  . 

^»         -^      '^^ 

Jt'  ■         ^-^ 

^   ': 

B^'l 

sl/ 

%-4 

r 

^T^^^^ 

Fig.  579- — Vaginal  section  by  transverse         Fig.   580. — Vaginal  section  by  longitu- 
incision.  dinal  incision. 


Fig.  581. — Vaginal  section  by  combined  transverse  and  longitudinal  incisions. 


or  large,  raw,  oozing  surface),  the   gauze  strip  is  replaced  by  a 
T-shaped  rubber   drainage-tube,   which   is    inserted  in   the    grip 
41 


642        The  Detailed  Technic  of  Gynecic  Surgery 

of  a  dressing  forceps,  and  usually  remains  ten  days.  By  at- 
taching a  straight-tip  medicine  dropper  to  the  tube  of  a  foun- 
tain syringe  and  inserting  its  tip  in  the  drainage-tube  the  pelvic 
cavity  or  closed  space  to  be  drained  may  be  irrigated  daily  with 
sterile  water  or  weak  permanganate  of  potassium  solution,  the 
water  flowing  out  alongside  the  tube.      If  the  bases  of  the  broad 


Fig.  582. — Field  of  operation  in  a  vaginal  operation  exposed  by  a  fenestrated  sheet, 
which  protects  the  rest  of  the  interfemoral  space. 


ligaments  are  cut  free  from  the  uterus,  care  should  be  exercised 
to  include  the  portions  on  the  median  side  of  the  ligature  around 
the  uterine  artery  in  at  least  one  stitch  on  each  side  of  the 
vaginal  vaults;  otherwise  the  cervix  and  vaginal  vaults  may  be 
robbed  of  their  strongest  support  (the  cardinal  ligaments  of  the 
cervix)  and  a  prolapse  may  result. 

The  Technic  of  a  Plastic  Operation. — The  patient,  if  possi- 


The  Technic  of  a  Plastic  Operation 


643 


ble,  should  be  prepared  for  forty-eight  hours  beforehand  by  a 
purgative  on  two  successive  nights,  rest  in  bed,  two  examinations 
of  the  urine,  and  a  modified  diet.  The  pudendal  hair  should  be 
clipped  with  a  clipper  and  shaved  with  a  safety  razor.  The 
vagina  is  irrigated  with  sublimate  solution,  i  :  4000,  followed 
by  sterile  water ;  it  is  then  packed  with  sterile  gauze.      Before 


Fig.  583. — Sheets  and  towels  draped  around  the  patient,  giving  more  room  than 
is  aftorded  by  the  arrangement  in  figure  582.  Necessary  for  such  an  operation  as  re- 
section of  the  pudic  nerves. 


the  operation  there  should  be  repeated  irrigations  of  the  lower 
bowel  until  it  is  completely  empty.  Six  to  twelve  injections  of  a 
pint  to  a  quart  of  salt  solution  should  be  used,  40  grains  to  the 
pint.  The  limbs  are  protected  by  canton  flannel  leggings.  The 
legs  are  supported  by  upright  leg-holders  and  stirrups.  Two 
assistants,  one  at  each  side  of  the  table,  and  a  nurse  to  thread 
needles  and  to  hand  instruments,  are  required.      Instead  of  the 


644      The  Detailed  Technic  of  Gynecic  Surgery 

gauze  pads  used  in  abdominal  surgery,  sea  sponges  ^  are  used, 
soaked  overnight  ina  i  :  1000  sublimate  solution,  and  rinsed  out 
before  use  in  sterile  water.  They  are  used  only  once.  The  op- 
erator, assistants,  and  nurse  wear  rubber  gloves.  The  field  of 
operation  is  protected  by  wrapping  a  sterile  sheet  around  each 
of  the  patient's  legs,  la)'ing  a  sterile  towel  over  the  pubis  and 
tucking  another  one  under  the  buttocks  and  over  the  Kelly  pad 
on  which  they  rest.  Another  plan  is  to  drape  over  the  limbs 
and  genitalia  a  sheet  with  an  oval  opening,  6  inches  long  and  2 
inches  wide,  hemmed  with  tape,  exposing  the  vulva,  but  protecting 


Fig.    584. — Abdominal  diessings  held  in  place  by  tapes  in  a  patient  in  whom  an 
abdominal  section  followed^  a  plastic  operation  for  cystocele. 


the  anus.  If  an  abdominal  section  is  to  follow  the  plastic  opera- 
tion, tapes  fastened  to  the  abdominal  binder  must  be  tied  around 
the  thighs,  to  hold  the  abdominal  dressings  in  place  (Fig.  5'^4)- 
The  instrument  table  is  on  the  left;  another  table  is  on  the  right, 
with  three  bowls  containing  respectively  tincture  of  green  soap, 
sterile  water,  and  sublimate  solution  (i  :  2000).  Back  of 
the  operator  is  the  douche  stand  with  two   douche  jars,  one  for 

^  The  preliminary  preparation  of  sea  sponges  is  as  follows  :  They  are  beaten, 
dry,  to  get  the  sand  and  dirt  out  of  them  ;  they  are  washed  in  running  water  for 
twenty-four  hours  ;  submerged  in  a  solution  of  hydrochloric  acid,  fjij-Oj  of  water, 
for  twelve  hours  ;  washed  in  sterile  water  ;  dipped  in  a  saturated  solution  of  per- 
manganate of  potassium  ;  immediately  transferred  to  a  saturated  solution  of  oxalic 
acid  ;   washed  again  in  sterile  water  and  preserved  in  a  I  :  40  carbolic  acid  solution. 


Dilatation   and   Curettage  645 

sterile  water,  one  for  sublimate  solution  (i  :  2000).  On  tlie 
operator's  right  hand  is  a  basin  on  a  stand,  filled  with  sterile 
water,  to  rinse  off  curets,  to  deposit  instruments,  etc.  The 
operator  or  his  assistant  cleanses  the  vulva  and  then  the  vagina  with 
pledgets  of  sterile  cotton,  tincture  of  green  soap,  and  water  ;  finally 
the  vulva  and  vagina  are  scrubbed  with  pledgets  of  cotton 
soaked  in  the  sublimate  solution.  This  is  quicker  and  more  ef- 
fectual than  the  douche.  The  author,  many  years  ago,  used 
the  continual  stream  of  water  over  denuded  surfaces  in  plastic 
surgery,  but  soon  gave  it  up  as  unnecessary,  and  indeed  disad- 
vantageous. A  good  assistant  with  sea  sponges  keeps  the 
field  of  operation  cleaner  and  drier  than  is  possible  with  the  con- 
tinuous irrigation. 

Dilatation  of  the  cervix  and  curettage  of  the  uterine  cavity 
are  a  part  of  so  many  gynecological  operations  that  the  description 
of  their  technic  has  been  postponed  to  the  section  on  operative 
technic  in  general.  They  are  required  for  the  coexistent  endo- 
metritis as  a  part  of  the  operative  treatment  of  displacements  of 
the  uterus,  of  all  the  plastic  operations,  and  of  many  of  the 
operations  for  pelvic  infections  and  inflammations,  as  well  as  for 
dysmenorrhea  and  sterility. 

Technic. — The  anterior  lip  of  the  cervix  is  seized  with  a  double 
tenaculum  (Fig.  503).  The  small-sized  Goodell  or  Baer  dilator  is 
inserted  and  separated  to  about  three-fourths  of  an  inch.  The 
Wathen's  heavy  dilator  is  next  used  up  to  an  inch,  five  or  ten 
minutes  being  consumed  in  the  dilatation.  Next  the  four- 
branched  Cleveland  dilator  is  used  and  screwed  up  to  70  or 
90  on  the  scale.  The  author  has  used  this  instrument  for  the 
past  two  years  and  secures  better  results  with  it  than  with  any 
other  instrument;  but  a  considerable  dilatation  must  first  be 
effected  before  it  can  be  inserted.  A  four-branched  dilator  is 
much  better  in  principle  than  one  with  two  branches,  Avhich 
to  be  effectual  must  be  used  in  two  different  directions,  but  only 
stretches  the  cervix  in  one  way  at  a  time,  and  subjects  it  to  more 
danger  of  injury  with  less  dilatation  than  does  the  four-branched 
instrument.  After  the  last  dilator  has  remained  in  place  for  about 
five  minutes  at  its  full  expansion,  the  blades  are  again  approxi- 
mated and  the  instrument  is  withdrawn.  The  four  walls  of  the 
uterine  cavity — anterior,  posterior,  lateral,  and  its  roof — are  then 
scraped  with  the  sharp  edge  of  a  Sims'  curet,  each  at  least  a  half 
dozen  times,  the  handle  being  held  between  the  thumb  and  forefin- 
ger and  the  blade  pressed  firmly  enough  against  the  endometrium 
to  cut  into  and  remove  it,  but  not  so  forcibly  as  to  penetrate  the 
firmer  myometrium.  When  the  endometrium  is  scraped  off,  a 
grating  sensation  is  communicated  to  the  curet.      The  Sims'  curet 


646       The  Detailed  Technic  of  Gynecic  Surger}^ 

is  removed  and  the  endometrium  brought  with  it  is  dropped  in  a 
vessel  containing"  a  10  per  cent.  formaHn  solution,  or  absolute 
alcohol,  to  prepare  it  for  microscopical  examination.  The  Sims' 
caret  does  not  fit  in  the  uterine  cornua  well,  and  may  leave  frag- 
ments of  hypertrophied  or  diseased  endometrium  there.  It 
should  always  be  followed,  therefore,  by  a  Martin's  curet,  with 
especial  attention  to  the  endometrium  of  the  fundus  and  the  cor- 
nua. Finally,  an  P^mmet's  curet  forceps  should  always  be  in- 
serted to  the  fundus,  opened  and  closed  in  all  directions  to  detect 
and  to  remove  a  polyp  which  a  curet  will  repeatedly  slip  over. 
The  operation  is  concluded  by  an  intra-uterine  douche  of  sterile 
water,  through  a  Fritsch-Bozeman  catheter. 


Fig-  585- — Many-tailed  binder  on  wheeled  stretcher,  on  which  patient  is  laid  after  her 
removal  from  the  operating  table. 


Gauze  packing  after  a  curettage  is  only  necessary  or  desirable 
if  there  is  free  bleeding,  which  very  rarely  occurs.  The  uterus 
is  packed  full  of  gauze  in  a  strip  two  inches  wide,  sterilized  in  a 
large  test-tube  ;  it  is  removed  in  twelve  hours.  The  practice  of 
leaving  a  tube  of  any  kind  in  the  cervix  and  uterus  to  maintain 
dilatation  for  some  days  is  not  commendable.  In  a  considerable 
proportion  of  cases  the  foreign  body  reduces  the  resisting  power 
of  the  raw  surface  in  the  uterine  cavity,  or  becomes  foul  by  the 
decomposition  of  blood  upon  it,  and  there  is  infection  of  the 
endometrium  and  of  the  Fallopian  tubes. 

The  After=treatment  of  an  Abdominal  Section. — The  Trans= 

portation  of  the  Patient  from  the  Operating  Table  to   Bed On   a 

wheeled  stretcher  brought  alongside  the  operating  table  there  is 


Preparation  of  the  Bed  and  External  Heat      647 

placed  an  air  cushion  the  whole  length  of  the  stretcher  ;  a 
blanket  and  the  abdominal  binder.  The  ankles  and  wrists  are 
released  from  the  straps  and  bandages  that  held  them.  The 
patient  is  lifted  from  the  operating  table,  with  her  trunk  and 
limbs  horizontal.  Letting  the  body  sag  in  the  middle  or  having 
it  jolted  or  jarred  in  any  way  is  carefully  avoided.  As  the  patient 
is  held  horizontally  for  a  moment,  a  nurse  cleanses  her  back  of 
blood  that  may  have  soiled  it.  She  is  then  placed  slowly  and 
gently  upon  the  stretcher  so  that  her  body  rests  upon  the  binder 
fi-om  the  buttocks  to  the  floating  ribs.  The  tails  of  the  binder 
are   brought   forward   and  fastened  with   safety  pins.       In   cold 


Fig.  586. — Many-tailed  binder  applied. 


weather,  a  cotton  jacket,  on  the  model  of  a  ]\Iurph}-  breast 
binder,  is  applied,  before  the  patient  leaves  the  operating  room, 
which  has  a  much  higher  temperature  than  the  halls  through 
which  she  passes.  The  blanket  on  which  she  lies  is  folded  over 
her.  Another  one  is  tucked  around  her  so  that  only  the  face  is 
exposed,  and  she  is  transported  to  her  bed  with  as  little  delay  as 
possible. 

The  Preparation  of  the  Bed  and  External  Heat. — The  bed  is 
prepared  so  that  the  woman  lies  between  blankets.  Under  that 
on  which  her  body  rests,  six  hot-water  bags  are  placed,  three  on 
each  side.  The  caps  must  be  screwed  tight,  so  that  there  shall 
be  no  leakage ;   the  temperature  of  the  water  should  not  be  over 


648       The  Detailed  Technic  of  Gynecic  Surgery 

I  50°  and  the  nurse  must  exercise  the  greatest  care  to  see  that 
the  patient's  skin  surface  is  protected  by  a  thick  layer  of  blanket 
and  nowhere  comes  in  contact  with  the  bags  ;  otherwise  serious 
burns  will  occur.  A  towel  is  pinned  under  the  patient's  head  to 
protect  the  bed  if  she  vomits.  The  body  is  covered  with  a 
blanket  and  the  ordinary  bed-clothes.  The  artificial  heat  is  re- 
moved when  the  temperature  has  reached  99°  F.  The  skin 
surface  of  the  limbs  and  chest  is  wiped  off  with  warm  alcohol  and 
water,  and  dried,  under  the  blanket. 

Guarding  a  Recent  Abdominal  Section. — The  nurse  in  charge  of 
an  abdominal  section  is  not  permitted  to  leave  the  patient  for  an  in- 


Fig.  587. — Bed  arranged  for  reception  of  patient.  A  trough  is  made  under  the 
blanket  by  hot-water  bags  on  either  side.  A  towel  is  pinned  to  the  lower  blanket 
under  the  patient's  head. 


stant  for  the  first  twenty-four  hours.  Relief  is  afforded  the  nurse 
when  necessary,  but  one  nurse  does  not  leave  the  bedside  until 
another  takes  her  place.  In  three  instances  in  the  author's  early 
practice  patients  left  their  beds  shortly  after  an  abdominal  sec- 
tion. In  one,  within  three  hours  after  the  removal  of  an  eleven- 
pound  myoma  from  the  broad  ligament,  the  woman  got  out  of 
bed,  walked  across  the  room,  seized  a  large  wash-basin  full  of 
cracked  ice,  and  drained  the  quart  or  more  of  ice-water  that  it 
contained  to  the  last  drop.  She  suffered  no  other  inconvenience 
than  a  prolonged  and  excessive  vomiting.  In  another,  a  patient 
in  the  Philadelphia  Hospital,  twenty-four  hours  after  a  double 
salpingo-oophorectomy,  became  maniacal,  sprang  from    her  bed, 


Diet — Bowels  649 

seized  the  bed-clothes,  waved  them  over  her  head,  and  fled 
along  one  of  the  corridors,  shrieking  at  the  top  of  her  voice. 
She  was  chased  for  several  minutes  by  the  terrified  nurses  before 
she  was  captured  and  returned  to  bed.  She  developed  no  un- 
toward symptom  whatever.  The  third  patient  had  a  nightmare 
the  second  night  after  a  myomectomy.  She  got  out  of  bed  and 
walked  some  distance  before  she  was  discovered.  Her  wound 
had  been  sewed  with  catgut.  It  burst  open  from  top  to  bottom, 
and  her  small  intestines,  as  we  discovered  the  following  day,  lay 
upon  the  abdomen  under  the  dressings.  They  were  returned,, 
the  wound  resewed  with  interrupted  silkworm-gut  sutures,  and 
there  was  not  even  a  rise  of  temperature  to  indicate  that  any 
complication  had  occurred.  Although  these  cases  happened  to 
turn  out  well,  the  experience  is  not  one  that  an  operator  cares 
to  have  repeatedly. 

Diet. — For  twenty-four  hours  the  patient  receives  nothing 
by  the  mouth.  She  is  then  given  one  dram  of  milk  and  one 
dram  of  lime-water  every  hour  for  three  hours.  If  her  stomach 
is  retentive,  the  milk  is  increased  by  a  dram  every  hour  till  she 
is  taking  an  ounce,  the  lime-water  being  kept  at  a  dram.  Bi- 
carbonate of  soda,  5  grains,  or  milk  of  magnesia,  i^ixv,  may  be 
substituted  for  the  lime-water  if  the  stomach  is  irritable.  Two 
drams  of  cool  water  are  given  midway  between  the  milk  feedings. 
No  cracked  ice  is  allowed.  If  there  is  a  tendency  to  tympany 
or  the  patient  objects  to  milk,  two  drams  of  barley-water,  alter- 
nating with  two  drams  of  clear  animal  broth,  are  given  every 
hour  for  three  hours  ;  then  in  increased  amounts  by  a  dram  an 
hour,  till  an  ounce  is  reached.  At  the  end  of  twenty-four  hours 
the  feeding  interval  is  increased  to  two  hours,  the  quantity  to 
two  ounces,  and  the  water  midway  between  the  feedings  to  half 
an  ounce.  After  the  third  day,  a  soft  diet,  gradually  increased 
in  variety  and  amount,  is  allowed. 

If  the  stomach  is  unretentive,  mouth-feeding  is  not  persisted 
in.  Rectal  injections,  every  four  hours,  of  predigested  beef  (one 
ounce)  and  normal  salt  solution  (four  ounces)  are  substituted. 
In  addition,  an  enema  of  eight  ounces  of  salt  solution  is  required 
twice  a  day  to  supply  fluid  to  the  circulatory  apparatus.  One 
submammary  injection  a  day,  of  a  pint,  is  often  preferable  to  the 
enema. 

Bowels. — At  the  end  of  twenty-four  hours,  an  enema  of  tur- 
pentine (f.3ss),  magnes.  sulph.  (.dSs),  glycerin  (fSj),  and  water 
(f.^ij)  is  given,  to  relieve  tympany,  which  it  usually  does 
effectually.  At  the  end  of  forty-eight  hours  one-eighth  grain 
of  calomel  is  given  every  hour  for  eight  doses.  Two  hours 
after    the    last    dose,    two    ounces    of   citrate    of   magnesia    are 


650       The  Detailed  Technic  of  Gynecic  Surgery 

given  every  two  hours,  midway  between  the  feedings,  for  three 
doses,  foUowed  by  another  compound  enema  of  glycerin,  Epsom 
salts,  turpentine,  and  water.  During  the  rest  of  the  con- 
valescence cascara  sagrada  (gtt.  x-xx,  fluid  extract)  at  night 
and  effervescent  phosphate  of  soda  (5ij)  in  a  tumbler  of  hot 
water  in  the  morning  are  usually  the  best  laxatives.  If  there  is 
excessive  tympany  or  the  bowels  are  very  difficult  to  move,  a 
half  grain  of  calomel  is  given  every  hour  for  six  doses,  followed 
two  hours  later  by  a  quarter  grain  of  elaterium,  and  two  hours 
later  by  the  compound  enema.  An  alternative  plan  of  treatment 
is  Y^¥  grai'^  of  eserin,  hypodermatically,  followed  by  turpentine 
niv,  in  emulsion  every  two  hours  by  the  mouth,  for  six  doses, 
and  by  an  enema  of  four  ounces  hot  milk  of  asafetida.  The  in- 
sertion of  the  rectal  tube  from  time  to  time  permits  the  escape 
of  flatus  and  gives  great  comfort  to  the  patient. 

Auscultation  determines  the  existence  of  intestinal  peristalsis. 
Its  absence,  with  enormous  tympany  and  grave  systemic  symp- 
toms, denotes  peritonitis  or  paralysis  of  the  bowel.  Either  con- 
dition is  well-nigh  hopeless.  Reopening  the  abdomen  and 
puncturing  the  bowel  in  a  number  of  places,  closing  the  puncture 
wounds  afterward,  is  indicated  for  paralysis.  Reopening  the 
wound,  irrigating  the  abdominal  cavity,  allowing  the  wound  to 
gape,  packing  it  with  gauze,  and  draining  Douglas's  pouch  with 
a  tube  are  indicated  for  septic  peritonitis. 

Secondary  or  continued  hemorrhage  is  one  of  the  rarest  com- 
plications following  an  abdominal  section  after  the  operator  has 
acquired  skill  and  experience.  It  is  due  almost  without  excep- 
tion to  an  error  of  technic  or  to  unreliable  ligature  material.  If 
cumol  gut  is  used  as  a  ligature,  the  assistant  who  threads  the 
needle  with  it  should  test  each  strand  before  he  hands  it  to  the 
•operator,  by  traction  and  by  jerking  it.  If  the  ligature  material 
is  sound  and  is  not  absorbed  too  quickly,  the  explanation  of  the 
hemorrhage  is  found  in  a  faulty  application  of  the  ligature  or  an 
insecure  knot.  Catgut  should  invariably  be  tied  in  three  knots. 
It  is  true  that  a  tighter  knot  is  tied  with  catgut,  if  the  first  is 
.single  and  the  next  is  a  surgeon's  knot,  with  another  single  knot 
on  top  of  it,  but  there  is  danger  of  the  ligature  slipping  if  the 
first  knot  is  single,  before  the  second  knot  is  tied,  so  that  I  prefer 
tying  silk  and  catgut  alike  ;  first  a  surgeon's  knot,  then  a  single 
knot,  and,  in  the  case  of  catgut,  another  single  knot. 

Before  closing  the  abdomen,  a  most  careful  search  is  made 
for  bleeding  and  oozing  points.  A  common  source  of  bleeding 
after  an  operation  is  a  slight  injur)^  to  the  free  edge  of  the  broad 
ligament  above  and  to  the  outer  side  of  the  ligature  around  the 
•ovarian  artery.      Omental  and   mesenteric   adhesions   stand  next 


Leukocyte-count  65 1 

in  frequency  as  sources  of  hemorrhage,  and  finally  bleeding  points 
not  included  in  the  ligatures  of  the  six  arteries  of  the  broad  liga- 
ments may  be  found  in  the  bottom  of  the  pelvic  cavity.  This 
region  should  always  be  investigated  if  there  is  any  oozing,  by  using 
broad  retractors  for  the  abdominal  walls  and  having  a  nurse  throw 
a  powerful  light  into  the  bottom  of  the  pelvis  with  a  shaded  hand 
electric  light,  while  the  patient  is  in  the  Trendelenburg  posture. 

If  symptoms  of  mternal  hemorrhage  appear  after  the  abdomen 
is  closed,  they  cannot  be  recognized  too  soon.  In  my  experi- 
ence 1  the  signs  of  bleeding  usually  appear  within  six  hours  of  the 
operation.  In  one  case  of  hemorrhage  from  the  puncture  of  a 
pedicle  needle  and  a  mass  ligature  many  years  ago  (which  could 
not  occur  if  the  ligature  were  properly  placed  and  tied),  the 
symptoms  only  became  unmistakable  after  twenty-four  hours  ; 
the  abdomen  was  reopened  and  the  broad  ligament  retied  with  a 
favorable  result.  The  only  treatment  is  to  open  the  abdomen, 
wash  out  the  blood,  seek  the  bleeding  point  or  area,  and  secure 
it  with  a  ligature  or  ligatures,  the  patient  receiving  a  submam- 
mary or  intravenous  injection  of  normal  salt  solution  and  stimu- 
lants hypodermatically  before,  during,  and  after  the  operation. 
Unfortunately,  the  secondary  operation  is  not  often  successful. 
By  the  time  it  is  obviously  necessary,  the  patient  is  in  poor  con- 
dition to  stand  it. 

It  is  often  exceedingly  puzzling  to  differentiate  postoperative 
shock  from  hemorrhage.  They  have  many  symptoms  in  com- 
mon ;  but  in  intra-abdominal  hemorrhage  the  abdomen  is  even- 
tually distended,  there  is  not  the  leaking  skin  of  shock,  the 
temperature  falls  again  after  the  primary  reaction  following  the 
operation,  there  is  steadily  increasing  pallor  of  the  face,  lips,  and 
gums,  the  pulse  steadily  loses  volume  and  becomes  more  com- 
pressible, rapid,  and  fluttering,  and  there  is  air  hunger. 

Leukocyte=count. — There  is  always  a  leukocytosis  after  an 
abdominal  section,  or  any  other  surgical  operation,  rapidly  sub- 
siding if  everything  goes  Avell,  or  recurring  and  persisting  if  there 
is  a  subsequent  infection  or  inflammatory  action.  It  is  an  inter- 
esting observation  to  note  the  proportion  of  leukocytes  day  by 
day  after  an  operation,  but  there  is  so  little  practical  utility  in  it 
that  to  the  author's  mind  it  is  not  worth  the  annoyance  to  the 
patient  and  the  trouble  to  the  hospital  staff,  as  a  routine  practice. 
The  pulse,  temperature,  distention  of  the  abdomen,  tenderness, 
localized  exudate,  the  patient's  condition  and  expression,  are 
much  more  valuable  guides  to  her  condition. 

1  The  last  case  of  secondary  or  continued  hemorrhage  in  my  services  occurred 
more  than  six  years  ago.  Up  to  that  time  the  accident  occurred  occasionally,  at  long 
intervals  ;   more  frequently  at  first  than  later. 


6^2  The  Detailed  Technic  of  Gynecic  Surgery- 
Rest  and  Confinement  to  Bed. — The  supine  position  must  be 
maintained  for  three  weeks.  Rolhng  from  side  to  side  or  any 
exertion  max-  weaken  the  fascia  or  at  least  stretch  the  skin  union 
and  spoil  the  appearance  of  the  wound.  At  the  end  of  three 
weeks  the  patient  begins  to  get  up  for  short  periods  at  a  time. 
It  should  be,  as  a  rule,  four  Aveeks  before  she  goes  out,  A  much 
shorter  convalescence  is  possible,  but  not  so  advantageous  to  the 
patient,  who,  if  she  is  hurried  out,  has  a  tedious  and  often  un- 
satisfactory convalescence  to  complete  at  home. 

The  first  dressing  of  tlie  wound  is  made  at  the  end  of  eight  or 
ten  days  if  the  temperature  remains  normal ;  otherwise  at  the 
end  of  a  week  or  less.  Gowns  and  gloves  are  sterilized  as  for 
the  operation.  A  probe,  medicine  dropper,  scissors,  and  tissue 
forceps  are  boiled  in  an  instrument  pan.  A  bundle  pinned  in  a 
towel,  of  two  sheets,  six  towels,  cotton  and  gauze,  is  sterilized 
in  the  autoclave.  The  strips  of  plaster  are  loosened  with 
alcohol  or  benzine  and  are  removed  with  the  dressing  by  a  nurse. 
The  surgical  dresser  has  prepared  himself  as  though  about  to 
operate,  and  is  protected  by  a  long-sleeved  gown  and  gloves. 
The  abdomen  is  surrounded  with  four  sterile  towels  ;  the  silver 
foil  and  its  paper  covering  are  removed  by  tissue  forceps  or  the 
fingers.  A  pledget  of  cotton  soaked  in  sublimate  solution,  i :  2000, 
is  laid  over  the  wound.  The  surrounding  skin  is  rubbed  with 
alcohol  on  pledgets  of  sterile  cotton.  The  wound  is  exposed. 
Any  dried  or  clotted  blood  is  carefully  removed  with  tissue  for- 
ceps. The  loop  of  the  subcuticular  stitch  is  gently  pulled  upon. 
It  is  of  fine  catgut  and  usually  comes  off  at  its  points  of  insertion 
and  emergence  in  the  skin.  If  not,  the  upper  end  is  cut  and  it 
is  pulled  out  from  above  downward.  The  wound  and  surround- 
ing skin  are  dried  with  a  sterile  towel  or  pledgets  of  gauze. 
Gauze  squares  are  laid  over  the  wound  and  surrounding  skin. 
The  dressing  is  held  in  place  by  strips  of  yellow  surgical  plaster 
two  inches  wide  and  long  enough  to  reach  two-thirds  around 
the  abdomen  made  adhesive  by  heat,  and  an  abdominal  binder. 
The  zinc  oxid  plaster  can  not  be  reapplied,  as  it  sticks  too  tightly 
and  irritates  the  skin. 

The  second  dressing  is  made  three  or  four  days  later  by  the 
operator  or  his  dresser.  If  the  wound  looks  satisfactory  and  is. 
permanently  healed,  subsequent  dressings  every  third  or  fourth 
day  may  be  made  by  the  nurse. 

If  the  wound  is  infected  and  there  is  subcutaneous  suppura- 
tion, the  end  of  a  small  surgeon's  probe  may  be  inserted  in  the 
middle  of  the  infected  area  or  at  two  points  through  the  skin 
wound  to  allow  a  vent  for  the  discharge.  Through  these  small 
pinhole  openings  the  subcutaneous  area  may  be  irrigated  by  in- 


Abdominal   Supporter 


653 


jecting  peroxid  of  hydrogen,  half  strength,  followed  by  weak- 
permanganate  solution  (i  :  6000)  with  a  medicine  dropper.  There 
must  be  a  daily  dressing.  By  this  plan  a  perfect  appearance  of 
the  wound  ma)'  be  obtained  in  spite  of  infection. 

If  the  skin  parts  and  the  wound  gapes,  the  raw  surface  is 
painted  with  a  solution  of  nitrate  of  silver,  10  grs.— foj,  a  narrow 
.strip  of  gauze  is  laid  along  the  bottom  of  the  wound,  and  the 
skin  edges  are  drawn  together  as  closely  as  possible  with  narrow 
strips  of  zinc  oxid  plaster.  Five  times  in  the  last  eighteen  years 
the  author  has  had  the  experience,  startling  at  first,  of  seeing  the 
whole  wound  break  open  and  the  intestines  lying  out  on  the  ab- 
domen under  the  dressings.  The  accident  occurred  late, — after 
the  tenth  day — except  in  one  instance.  There  was  no  fever  or 
other  disturbance  of  health  except  slight  nausea.  The  intestines 
w^ere  cleansed  and  put  back  in  the  abdomen,  the  wound  was  brought 
together  by  interrupted  stitches  of  silver  wire  or  silkworm-gut,  and 


Fig.  588. — -Abdominal  supporter. 


a  strip  of  gauze  was  inserted  to  the  peritoneum  between  two  of  the 
sutures.  In  one  or  two  cases  no  anesthesia  was  employed;  in  the 
others,  a  w^hiff  or  two  of  gas  and  ether  were  given.  All  the  women 
recovered,  the  wounds  closed  by  granulation,  but  four  had  a 
hernia  which  was  repaired  by  a  subsequent  operation.  In  these 
cases  the  peritoneum  and  fascia  part  first;  the  skin  holds  for  some 
days  and  then  suddenly  gives  way.  In  one  case  it  was  known 
that  the  patient  got  out  of  bed  ;  in  another  there  was  uncontrol- 
lable and  violent  hiccoughing  for  some  days  after  the  operation. 
In  a  third — an  operation  for  a  gangrenous  ovarian  cyst  after  labor 
— there  were  extreme  tympany  and  violent  retching.  The  other 
two  were  inexplicable.  Two  of  the  wounds  had  been  closed 
layer  by  layer  with  catgut ;  three,  a  number  of  years  ago,  by 
close-set  interrupted  sutures  of  silkworm-gut. 

Abdominal  Supporter. — It   is    good   policy  to    recommend  an 
abdominal  binder  to  be  worn  for  six  months  after  an  abdominal 


654        il^^  Detailed  Technic  of  Gynecic  Surgery 


section.  The  integrity  of  the  wound  depends  on  the  way  it  is 
sutured  and  the  care  of  the  patient  afterward.  A  binder  will  not 
prevent  a  hernia  if  there  is  fault}- junction  of  the  fascia  or  the 
wound  is  strained  in  the  patient's  early  convalescence  ;  but  it 
often  gi\'es  comfort,  especially  in  stout  women  with  a  tendency 
to  pendulous  abdomen,  and  in  such  women  it  does  support  the 
abdominal  walls  and  lessens  the  strain  on  the  cicatrix.      \Mien 

the  binder  is  relinquished  it  should 
be  replaced  for  a  time  by  a  Jaeger 
w^ool  bandage,  w'hich  is  gradually 
reduced  by  cutting  strips  off  it. 
Unless  this  precaution  is  observed 
a  violent  cold  ma}-  be  taken. 

The  Treatment  of  Shock  during 
and  after  an  Abdominal  Section. — 
The  anesthetizer  attends  to  the 
stimulation  of  the  patient  during 
the  operation.  A  tray  with  a  hy- 
podermatic needle,  strychnia,  digi- 
talis, and  nitroglycerin  is  close  at 
hand,  in  case  it  is  needed.  If  there 
is  anemia,  serious  loss  of  blood  be- 
fore or  during  an  abdominal  oper- 
ation, injections  of  normal  salt  solu- 
tion are  required.  It  is  a  convenient 
plan  to  have  in  the  operating  room 
sterile  flasks  of  the  modified  salt 
solution  (Hare's  formula)  of  double 
strength.  By  adding  an  equal 
quantit}-  of  hot  sterile  water,  the 
solution  is  immediateh^  ready  for 
use.  The  needle  for  injection  and 
the  glass  jar  with  rubber  cork  and 
bulb  syringe  attachment  (Clark's 
apparatus),  for  increasing  the  air- 
pressure  over  the  fluid,  are  steril- 
ized by  boiling  and  are  kept  always 
in  one  place,  ready  for  instant  use. 
The}^  are  prepared  for  ever\'  oper- 
ation. In  women  the  most  convenient  and  quickest  wa}-  to 
inject  normal  salt  solution  is  under  the  breasts.  The  mammary 
gland  is  seized  and  lifted  off  the  chest  ;  a  nurse  cleanses  a  spot 
of  skin  with  alcohol  on  the  periphery  of  the  base  of  the  breast. 
The  needle  is  inserted  horizontally  so  it  shall  not  penetrate  the 
pleura  (an  accident  I    once   saw) ;  the  air-pressure  is  increased 


589. — Apparatus  for  hypo- 
dermoclysis. 


Sequeke  of   Abdominal  Surgery  655 

over  the  fluid  in  the  jar,  which  is  held  at  a  considerable  height 
above  the  patient ;  the  breast  is  kneaded  and  rubbed  to  hasten 
the  absorption  of  the  fluid  under  it.  The  puncture  wound  is 
closed  with  collodion  and  cotton  after  the  needle  is  withdrawn. 
There  is  no  question  that  a  patient  responds  more  quickly  to 
intravenous  than  to  submammary  injections,  but  it  requires  time 
and  is  not  always  easy  to  cut  down  upon  the  median  basilic 
vein,  to  insert  the  needle  into  it,  and  to  place  a  ligature  around 
the  needle  in  the  vein  and  another  one  below  it.  It  is  quite  fre- 
quently possible,  however,  to  grasp  the  arm  above  the  elbow,  to 
make  the  vein  stand  out  under  the  skin,  to  cleanse  the  skin  over 
it  with  alcohol,  and  to  insert  the  needle  directly  into  the  vein 
through  the  skin. 

Normal  salt  injections  may  be  required  after  the  patient  is 
placed  in  bed.  They  are  never  harmful  and  often  do  the  greatest 
good.  An  injection  every  twelve  or  eight  hours,  of  a  pint  under 
each  breast,  is  the  usual  routine  order.  In  the  most  serious  cases 
10  minims  of  the  i  :  1000  adrenalin  solution  should  be  added  to 
each  pint  of  normal  salt  solution.  In  addition,  artificial  heat  is 
continued  until  reaction  is  established  ;  a  hypodermatic  injection 
of  digitalis  (^x)  and  strychnia  sulphate  (gr.  J-g-)  is  ordered 
every  four  hours.  Alternating  with  the  hypodermatic  injections, 
an  enema  is  injected  of  one  ounce  of  predigested  beef,  four  ounces 
of  normal  salt  solution,  carbonate  of  ammonia,  gr.  xx,  and 
whisky,  f-Sss.  Nitroglycerin  (y^  gr.)  and  inhalations  of  oxy- 
gen are  reserved  for  emergencies.  The  stimulation  is  naturally 
reduced  as  the  patient's  condition  improves. 

Sequelae  of  Abdominal  Surgery. — Abdominal  Hernia. — In  the 
days  when  it  was  customary  to  unite  the  abdominal  wound  by 
interrupted  sutures,  it  was  commonly  acknowledged  that  a  hernia 
must  be  expected  in  about  10  per  cent,  of  the  cases.  Since  the 
development  of  a  better  technic,  closure  of  the  wound,  layer  by 
layer,  with  durable  catgut,  the  proportion  of  hernise  is  not  one- 
tenth  what  it  was.  They  ought  really  to  be  unknown  if  the 
suture  material  is  perfectly  reliable  in  tensile  strength  and  dura- 
bility, if  the  woman's  tissues  are  fairly  healthy,  if  no  unusual 
strain  is  imposed  upon  the  wound,  and  if  the  patient  is  confined 
to  bed  long  enough  ;  but  as  there  is  always  a  possible  fault  in 
one  of  these  particulars,  a  hernia  after  an  abdominal  section  is  not 
yet  absolutely  avoidable.  Fortunately  the  technic  of  their  per- 
manent cure  by  surgical  means  has  advanced /(^r/ /^.y^//  with  the 
improved  technic  of  closing  the  abdominal  wound,  so  that  no 
one  need  suffer  from  the  discomfort  and  dangers  of  an  abdom- 
inal hernia  following  an  operation  who  will  submit  to  the  neces- 
sary treatment. 


656       The  Detailed  Technic  of  Gynecic  Surgery 

A  long  abdominal  incision  is  made  extending  above  to  the 
umbilicus,  below  to  the  symphysis,  and  encircling  the  hernial 
pouch.      The  skin  of  the  latter  is  nicked  with  a  knife,  with  care 


Fig.  590. — Umbilical  hernia. 


Fig.  591. — Hernia  in  the  scar  of  an  abdominal  section. 


not  to  injure  the  intestinal  loops  in  it.  The  whole  sac  is  laid 
open.  Intestinal  and  omental  adhesions  are  severed  and  the  con- 
tents of  the  sac  are  returned  within  the  abdomen.  The  whole 
sac  is  excised.      The  skin  and  fat  above  and  below  it  are  dis- 


Sequelae  of   Abdominal   Suro^ery 


657 


sected  back  till  both  recti  muscles  are  exposed  the  whole  length 
of  the  wound.  The  tissues  matted  together  around  the  hernial 
ring  are  separated  b\'  a  flap-splitting  dissection.  The  sheaths  of 
the  recti  muscles  are  split  the  whole  length  of  the  wound.  The 
abdominal  opening  is  closed  by  uniting  the  peritoneum  and  super- 
imposed fascia.  Four  to  six  mattress  sutures  are  inserted 
through    the    outer    edges   of   the  sheaths   of    both   recti,   skip- 


Fig.  592. — Degeneration  of  the  abdominal  walls  with  multiple  hernise. 


ping  the  tissues  between.  Silkworm-gut  sutures  are  inserted 
through  the  skin,  fat,  and  outer  edges  of  the  sheaths  of  the  recti 
muscles.  The  mattress  sutures  are  tied  ;  the  outer  edges  of  the 
recti  sheaths  are  united  with  formalin  catgut  (No.  3)  in  a  contin- 
uous suture.  The  fat  is  united  by  a  double  tier  running  stitch  of 
fine  catgut.  The  skin  is  united  with  a  continuous  suture  of 
catgut  and  the  interrupted  silkworm-gut  sutures  are  tied.  If  the 
42 


658       The  Detailed  Technic  of  Gynecic  Surgery 

structures  of  the  abdominal  wall  are  fairly  healthy,  this  technic 
promises  a  permanently  good  result. 

There  is  occasionally  a  curious  degeneration  of  the  ab- 
dominal wall,  making  it  incapable  of  adequately  supporting 
the  intra-abdominal  contents.  The  closure  of  a  hernia  in 
one  place  is  followed  by  the  development  of  others  almost 
immediately. 

A  sinus  following  abdominal  section  is  rare  if  permanent  suture 
material  is  avoided  in  cases  of  infectious  or  inflammatory  pro- 
cesses, especially  in  those  requiring  drainage.  Permanent  sutures 
to  suspend  the  uterus  and  permanent  sutures  to  unite  the  fascia  in 
the  abdominal  wall  are  particularly  liable  to  excite  irritation  and 
suppuration  and  so  to  develop  a  sinus.  I  have  removed  silk- 
worm-gut and  silver  wire  sutures  from  the  fascia  inserted  by  other 
operators.  In  one  case  a  woman  developed  an  abscess  around 
two  silk  sutures  in  the  fundus  uteri  a  year  after  the  operation,  and 
in  another  seven  years  after  the  insertion  of  two  silkworm-gut 
sutures  to  suspend  the  uterus.  In  both  cases  it  was  necessary  to 
reopen  the  wound  to  the  fundus  uteri  and  to  remove  the  sutures.^ 
If  the  knots  of  the  suspension  sutures  are  tied  inside  the  peri- 
toneal cavity  (page  290,  Fig.  302),  it  is  not  likely  that  a  sinus  will 
develop  even  in  the  remote  future.  A  sinus  dependent  upon  per- 
manent suture  or  ligature  material  will  not  heal  till  the  silk  or 
silkworm-gut  has  been  removed.  It  usually  comes  away  spon- 
taneously after  some  months,  but  can  often  be  extracted.  I  have 
found  nothing  so  good  for  this  purpose  as  a  surgeon's  probe, 
seized  at  its  point  in  a  hemostat  and  bent  into  a  right-angled 
hook.  With  this  implement,  patient  fishing  at  the  bottom  of 
the  sinus  is  often  rewarded  by  the  extraction  of  the  foreign 
body. 

If  there  is  no  foreign  body  at  the  bottom  of  the  sinus  to  keep 
it  open,  such  as  a  slough  or  ligature  material,  a  dressing  of 
alcohol  and  water,  equal  parts,  on  gauze,  often  hastens  its 
closure. 

Fecal  Fistula.  — If  the  bowel  is  perforated  when  the  abdomen  is 
opened  by  a  pelvic  or  abdominal  abscess  which  has  discharged 
through  the  intestines  ;  if  the  walls  of  the  bowel  are  infiltrated 
and  unhealthy,  and  are  subjected  to  pressure  in  subsequent  drain- 
age of  the  pelvis  ;  if  an  intestinal  anastomosis  has  been  at- 
tempted and  has  partially  failed  ;  if  the  bowel  coats  are  much 
injured  in  the  separation  of  adhesions  and  can  not  be  perfectly 
repaired,  a  fecal  fistula  may  result  through  the  abdominal  inci- 
sion.     In  the  majority  of  cases  the  fistula  closes  spontaneously  in 

^  The  original  operations  had  been  performed  by  other  surgeons.  I  could  not 
learn  whether  the  sutures  had  been  knotted  within  the  peritoneal  cavity. 


Femoral  Thrombophlebitis  659 

a  few  days  ^  or  at  most  a  few  weeks.  If  permanent  ligatures 
have  been  used,  they  must  be  extracted  ;  if  not,  the  case  should 
be  treated  expectanth'  for  nine  or  twelve  months,  as  the  sinus 
often  closes  gradually  in  that  space  of  time.  The  abdomen  is 
protected  by  a  pad  of  gauze  held  in  place  with  adhesive  strips, 
the  dressing  being  frequently  changed.  If  the  fistula  does  not 
close  in  a  year,  it  will  probably  never  heal  spontaneously,  and 
the  patient  is  exposed  to  considerable  risk  of  abscess-formation, 
obstruction  of  the  bowel,  or  pyemia.  I  have  seen  a  woman  die 
from  these  causes  as  late  as  four  years  after  the  establishment  of 
a  fecal  fistula.  Operative  treatment,  therefore,  should  be  pro- 
posed after  a  }'ear  or  before  that  time  if  aggravated  s}'mptoms 
appear. 

The  most  successful  operative  treatment  is  to  reopen  the 
abdomen,  protecting  the  external  orifice  with  a  pledget  of  cotton 
soaked  in  sublimate  solution,  1:1000;  to  dissect  out  the  sinus, 
which  is  usually  a  tubular  canal,  with  walls  of  organized  exudate, 
about  the  caliber  of  a  little  finger,  down  to  the  opening  in  the 
bowel  ;  to  enlarge  the  latter  by  clipping  away  its  infiltrated  edges, 
and  to  close  it  with  a  double  row  of  mattress  sutures,  unless  this 
plan  narrows  the  caliber  of  the  bowel  too  much.  In  such  a  case 
an  end-to-end  anastomosis  of  the  bowel  is  indicated,  the  portion 
containing  the  fistulous  opening  being  excised.  I  find  the 
O'Hara  forceps  the  best  instrument  for  the  purpose,  and  had  in- 
stinctively used  this  principle  with  ordinary  Pean  forceps  before 
the  O'Hara  instrument  was  invented. 

Femoral  Thrombophlebitis. — In  0.3  to  3  per  cent,  of  abdominal 
sections  there  is  a  postoperative  femoral  thrombophlebitis,  most 
often  on  the  left  side.  The  etiology  of  the  condition  is  obscure.  It 
is  often  due  to  a  mild  form  of  infection,  as  is  demonstrated  by  the 
following  facts  :  The  better  the  aseptic  technic,  the  smaller  is  the 
proportion  of  phlebitis  ;  ^  an  operator  may  have  a  very  unusual 
proportion  of  cases  for  a  period  of  some  months  and  not  again 
for  years  ;  ^  there  is  usually  elevated  temperature  and  at  least  a 
slight  acceleration  of  pulse.  Infection,  however,  is  not  the  sole 
explanation.  It  is  commonest  after  suspension  of  the  uterus  and 
hysterectomy,  and  not  after  operations  for  suppurative  conditions 
in  the  pelvis  ;  it  occurs  late,  after  the  eighth  da}',  and  is  practi- 

1  In  one  of  my  cases  a  perforation  of  the  rectum  was  found,  in  an  operation  for 
pelvic  abscess,  large  enough  to  admit  a  thumb.  The  pelvis  was  drained,  without  at- 
tempting to  close  the  hole  in  the  bowel;  the  fecal  fistula  closed  within  a  week;  the 
wound  was  perfectly  healed  in  three. 

-In  the  author's  last  300  abdominal  sections  there  has  only  been  one  case  of 
phlebitis,  in  an  operation  for  carcinoma  of  both  ovaries  and  the  uterus,  complicated  by 
tubercular  peritonitis. 

*  Dr.  Whitridge  Williams  told  me  that  during  one  winter  almost  every  case  he 
operated  upon  developed  phlebitis. 


66o       The  Detailed  Technic  of  Gynecic  Surgery 

cally  never  fatal.  Clark  ^  explains  it  by  a  primary  thrombosis 
of  the  epigastric  veins  due  to  pressure  from  abdominal  retractors 
or  to  inclusion  in  the  adhesions  or  sutures  of  a  uterine  suspen- 
sion. The  clot  extends  from  these  veins  into  the  femoral,  usually 
the  left,  in  which  there  is  greater  predisposition  to  thrombosis  on 
account  of  the  greater  length  of  the  left  common  iliac  vein,  its 
passage  under  the  artery,  and  the  pressure  to  which  it  is  subjected 
by  the  sigmoid  flexure. 

The  most  reasonable  explanation  is  found  in  a  combination 
of  factors  :  A  mild  infection  of  the  branches  of  the  epigastric 
veins  in  the  abdominal  walls  or  of  the  vein  of  the  round  ligament 
emptying  into  the  epigastric  ;  a  pressure  thrombosis  in  these 
veins  from  instruments  or  ligatures  ;  the  prolonged  retention  of 
the  patient  in  the  supine  position  with  the  legs  rigidly  extended  ; 
and  the  pressure  upon  the  groins  by  the  lower  edge  of  the 
abdominal  dressings,  the  last  two  factors  exerting  pressure  upon 
the  femoral  veins  themselves  and  predisposing  to  thrombosis,  es- 
pecially on  the  left  side. 

The  first  symptoms  are  pain  in  the  calf  of  the  leg  and  in  the 
groin,  with  a  moderate  rise  of  temperature  and  slight  acceleration 
of  the  pulse,  though  the  systemic  symptoms  may  be  scarcely 
noticeable.  The  leg  rapidly  swells,  becomes  milk-white  in  color, 
and  pits  on  pressure. 

The  treatment  is  elevation  of  the  limb  on  pillows,  its  envelop- 
ment in  cotton  and  a  lightly  applied  bandage  to  mitigate  the 
feeling  of  numbness  and  cold  in  it;  an  application  of  unguentum 
Crede  (soluble  silver)  along  the  course  of  the  femoral  vein,  and 
absolute  quiet,  with  avoidance  of  all  physical  effort  or  disturb- 
ance. 

The  symptoms  subside  slowh'.  Plenty  of  time  should  be 
allowed  for  the  liquefaction  of  the  thrombus  or  its  firm  organiza- 
tion, before  permitting  the  patient  to  get  up,  else  there  may  be 
a  cardiac  or  pulmonary  embolus,  with  a  fatal  result. 

The  After=treatment  of  a  Plastic  Operation. — The  gauze 
packing  is  removed  from  the  vagina  at  the  end  of  twenty-four 
hours.  It  should  be  one  of  the  most  stringent  rules  of  a  hos- 
pital service  that  the  nurse  in  charge  of  the  patient  must  attend 
to  this  duty.  The  author  has  seen  one  case  dangerously 
infected  by  a  vaginal  tampon  which  had  been  inserted  in 
another  hospital,  had  been  forgotten,  and  with  which  the  patient 
entered  the  author's  wards  in  the  Philadelphia  Hospital  some 
four  weeks  after  her  operation.  In  one  of  the  maternity  hos- 
pitals of  Philadelphia  an  intra-uterine  packing  for  hemorrhage 
was  forgotten.      The  patient  died  ten  days  later,  when  the  gauze, 

1  "  Univ.   of  Penna.  Med.  Bulletin,"  1902. 


Removal   of   Stitches  66i 

in  a  horribly  fetid  condition,  was  discovered  in  the  uterine  cavity. 
If  more  than  one  strip  of  gauze  has  been  inserted,  the  fact  must 
be  entered  on  the  patient's  chart  before  she  leaves  the  operating 
room. 

Catheterization  should  be  avoided,  if  possible.  It  is  not 
necessary  to  protect  the  wound,  which  is  guarded  in  the  vagina 
by  the  packing  for  the  first  twenty-four  hours  and  which  is 
cleansed  on  the  external  genitalia  by  pouring  sterile  water  over 
it  from  a  pitcher  while  the  patient  is  on  a  bedpan  after  each 
urination.  If  it  is  necessary  to  catheterize  the  patient,  the 
nurse  weai"s  sterile  rubber  gloves ;  the  patient's  thighs  are 
well  separated ;  the  labia  are  separated  by  the  thumb  and 
forefinger  of  one  hand  ;  the  vestibule  is  cleansed  with  a  pledget 
of  cotton  and  sublimate  solution  ;  the  sterile  catheter  is 
taken  from  the  pan  in  which  it  has  been  boiled,  is  dipped 
in  a  medicine  glass  containing  sterile  castor  oil,  and  inserted 
directly  into  the  external  meatus  without  touching  surround- 
ing tissues.  If  but  one  or  two  catheterizations  are  required,  the 
short  glass  catheter  is  most  convenient.  If  the  catheter  must 
be  used  for  a  considerable  time,  the  soft-rubber  catheter  is  pref- 
erable, as  it  does  not  irritate  the  urethra. 

The  vulva  is  cleansed  and  protected  by  irrigations  with  sterile 
water  after  each  urination  ;  by  dusting  with  xeroform  twice  or 
three  times  a  day,  and  by  a  wide  and  thick  vulvar  pad  of  sterile 
cotton  and  gauze  held  by  a  T-binder. 

If  there  is  secondary  hemorrhage  after  a  plastic  operation,  the 
bleeding  can  always  be  controlled  by  placing  the  woman  on  the 
operating  table,  removing  the  original  packing  and  douching  the 
vagina,  repacking  it  as  tightly  as  possible  without  straining  the 
stitches,  by  inserting  a  narrow-bladed  Sims'  speculum  to  distend 
the  vaginal  introitus  ;  placing  a  large  mass  of  gauze  over  the 
vulva,  and  applying  a  tight  T-binder. 

Douches  routinely  after  a  plastic  operation  are  a  disadvantage. 
About  the  fifth  or  sixth  day  a  sterile  water  vaginal  douche  is 
given.  After  that,  if  there  are  no  discharge  and  no  discomfort, 
a  douche  of  sterile  water  every  other  day  is  sufficient. 

The  bowels  are  moved  by  a  half  bottle  of  citrate  of  magnesia 
on  the  evening  of  the  second  day  ;  the  rest  of  the  bottle  the  next 
morning  before  breakfast,  followed,  if  necessary,  by  an  enema 
later  in  the  day. 

Removal  of  Stitches. — The  author  removes  stitches  himself 
from  both  ward  and  private  patients.  To  save  time  and  trouble, 
they  are  all  taken  out  on  the  fourteenth  day.  The  perineal 
sutures  may  be  removed  earher,  as  they  have  a  tendency  to  cut 
into  the  skin,  but  it  disturbs  the  patient  to  remove  sutures  twice 


662        The  Detailed  Technic  of  Gynecic  Surgery 


within  a  few  days  and  it  increases  the  work  of  the  operator.    The 
number  of  sutures  inserted  is  invariably  noted  upon  the  patient's 

chart  before  she  leaves  the  operating 
room.  Her  chart  is  brought  with  her 
to  the  operating  room  when  the  stitches 
are  removed. 

The  patient  is  put  on  the  table  in  the 
dorsal  position  with  her  legs  and  feet 
supported  on  uprights  and  stirrups  as 
though  for  a  plastic  operation.  The 
vaginal  sutures  are  displayed  by  a  very 
narrow-bladed  retractor  on  the  model  of 
a  Sims'  speculum.  The  ends  have  been 
left  an  inch  long  above  the  shot ;  they  are 
seized  with  a  hemostat,  one  blade  of  a 
sharp-pointed  scissors  is  inserted  below 
the  shot  between  the  strands,  one  strand 
is  cut,  and  the  suture  pulled  out.  If 
there  are  cervical  sutures  they  are  re- 
moved first,  by  inserting  a  narrow- 
bladed  bivalve  speculum,  virginal  size, 
distending  its  blades  moderately  and  illuminating  the  vagina  by 
an  electric  head-light.  Specially  constructed  scissors  and  for- 
ceps, enabling  the  operator  to  keep  his   hands   from   obstructing 


Fig.  593. — Narrow-bladed 
vaginal  retractor. 


Fig.  594.  —  Forceps  and  scissors  for  removing  cervical  stitches. 


the  light,  are  a  great  convenience.  The  author  does  not  like  the 
plan  of  bunching  a  number  of  suture  ends  together  and  clamp- 
ing them  with  a  large  shot.     It  makes  a  thick  rope  of  stitches  on 


Confinement  to   Bed  66 


o 


which  discharge  collects,  and  is  not  so  cleanly  as  leaving  the  in- 
dividual suture  ends  loose  and  about  an  inch  long. 

Confinement  to  Bed. — The  day  after  the  sutures  are  removed 
the  patient  begins  to  sit  up  in  bed.  She  gets  out  of  bed  three 
days  later  and  leaves  her  room  or  goes  home  as  soon  as  she  feels 
able.  Coitus  should  be  interdicted  for  at  least  six  weeks  after  a 
plastic  operation  in  the  genital  canal.  If  the  vaginal  introitus 
has  been  too  much  narrowed,  by  an  operation  for  rectocele, 
or  prolapse,  Hegar's  graduated  bougies,  used  for  vaginismus, 
obviate  the  difficulty. 


INDEX 


Abdomen,  hematocele  in,  437 

hematomata  in,  437 
Abdominal    hernia    as    sequel    of    ab- 
dominal section,  655 
hysterectomy      for     fibromyoma      of 

uterus,  343 
pregnancy,  clinical  history,  433 

symptoms,  439 
retractor,  586 

section,  abdominal   hernia   as   sequel 
of,  65  s 
abdominal  supporter  in,  653 
after-treatment,  646 
arrangement  of  tables  and  instru- 
ments, 611 
bowels  in,  649 
choice  of  catgut  or  silk  for  suture 

and  ligature  material,  626 
diet  in,  649 
drainage  in,  633 
enucleation  of  uterine  fibromj'oma 

by,  347 
examination  of  appendix  in,  626 
fecal  fistula  following,  65S 
femoral  thrombophlebitis  after,  659 
first  dressing  of  wound  in,  652 
for  extra-uterine  pregnancy,  440 
for  interstitial  pregnancy,  442 
for  tubal  pregnancy,  441 
incision  for,  615 
incision  for,  closure  of,  630 
incision  for,  dressing  of,  631 
leukocyte-count  in,  651 
mass  ligature  of  broad  ligament  in, 

618 
methods  of  securing  blood-vessels 

of  broad  ligaments,  and  treatment 

of  stump,  618 
packing    abdominal     cavity     with 

pads,  617 


665 


Abdominal    section,    position   of    assis- 
tants, 611 
preparation   of    bed,    and    external 

heat  in,  647 
preparation  of  patient  for,  600 
preparing  field  of  operation,  613 
recent,  guarding  of,  648 
rest   and    confinement    to   bed   in, 

652 
secondary  or  continued  hemorrhage 

in,  650 
securing  patient  on  table,  612 
separate     ligation     of    arteries     of 

broad  ligament  in,  619 
sequelae  of,  655 
shock  in,  treatment  of,  654 
sinus  following,  658 
technic  of,  611 
toilet  of  peritoneum  in,  628 
transporting  patient  from  operating 

table  to  bed,  646 
Trendelenburg  posture  in,  617 
supporter  in  abdominal  section,  653 
Abortion,  tubal,  436 
Abrasions  of  cervix,  206 
Abscess,  vulvovaginal,  96 
Actinomycosis  of  Fallopian  tubes,  412 
of  ovary,  461 
of  parametrium,  517 
Adenocarcinoma  of  cervdx,  228 
of  endometrium,  364 

age  for  development,  366 
diagnosis,  36S 
panhysterectomy  for,  369 
prognosis,  370 
symptoms,  368 
treatment,  369 
Adenoma,  malignant,  of  cervix,  230 
Adhesions,  ovarian,  treatment  of,  499 
Albiiginea,  445 


666 


Index 


Alexander's  operation   for  retroversion 

of  uterus,  284 
Allis'  forceps,  588 
Amenorrhea,  381 

etiology,  381 

symptoms,  382 

treatment,  382 
Amputation  of  cervix,  Hegar's  method, 
210 

of  subperitoneal  pedunculated  tumors 
for  uterine  fibromyoma,  349 
Amyloid  degeneration  in  fibromyoma  of 

uterus,  328 
Anastomosis,  ureteral,  for  fistula;,  551 
Anesthesia  and  anesthetics,  603 
Angiotribe,  626 
Anomalies   of    development    in   cervix, 

63 
in  genital  tract,  54 
in  vagina,  65 
in  vulva,  71 
of  hymen,  73 
Anteflexion  of  uterus,  270,  291 
cuneiform  exsections  for,  293 
Dudley's  operation  for,  293 
Anteposition  of  uterus,  291 
Ante-uterine  hematocele,  437 
Anteversion  of  uterus,  270,  291 
Apostoli's  treatment  for  fibromyoma  of 

uterus,  339 
Appendix,   examination  of,  in  abdom- 
inal section,  626 
Arbor  vitse,  201 

Atmokausis  for  menorrhagia,  385 
Atresia,  acquired,  of  cervix,  220 
treatment,  220 
of  vagina,  141 
etiology,  142 
symptoms,  142 
treatment,  144 
of  cervix,  63 
acquired,  220 
diagnosis,  63 
treatment,  64 
of  genital  tract,  74 
of  vulva,  71 
urethra?,  556 
symptoms,  556 
treatment,  556 


Atrophy  and  superinvolution  of  cervix, 

214 

lactation,  313 

of  fibromyoma  of  uterus,  332 
of  ovary,  458 
of  uterus,  313 
Autoclaves,  packing  of,  591 


Bandl's  operation  for  ureteral  fistulee, 

553 
Bartholin's  glands,  92 
Bifid  uterus,  61 

Bivalve  speculum,  method  of  introduc- 
ing, 29 
Bladder,  anatomy,  525 
carcinoma  of,  540 
contraction  of,  539 
diseases  of,  535 
displacements  of,  535 
fistulas    in,    541.      See    also    Urinary 

iistulcE. 
inspection  of  interior,  527 
malformations  of,  congenital,  535 
neoplasms  of,  540 
diagnosis,  540 
symptoms,  540 
treatment,  540 
polyp  of,  papillomatous,  540 
relations  of,  to  ureter,  525 
Blood  and  mucus,  retention  of,  within 
genital  tract,  74 
retention  of,   within  genital  tract, 
treatment,  78 
Bloodletting,  local,  50 
Bougie  carrier,  49 
Braun's  intra-uterine  syringe,  48 
Broad  ligament,  relations  of,  to  ureter 

524 
varicocele  of,  517 
Bulbocavernosus  muscle,  135 
Bulbus  ovarii,  446 
Buttle's  scarificator,  50 
Byrne's    operation    for    carcinoma    of 
cervix,  255 


Calcification  of  fibromyoma  of  uterus, 
330 


Index 


667 


Calculus,  vesical,  541 
Carcinoma  of  bladder,  540 
of  cervix,  225 

Byrne's  operation,  255 

clinical  history,  231 

combined  vaginal   and  abdominal 

hysterectomy,  242 
diagnosis,  232 
diagnosis,   by  freezing  microtome, 

238 
diagnosis,  differential,  240 
etiology,  226 
Finsen  rays  for,  261 
hysterectomy,     combined     vaginal 

and  abdominal,  242 
hysterectomy,  vaginal,  246 
pathology,  226 

recurrence  after  operation,  258 
Roentgen  rays  for,  261 
squamous-cell,  226 
symptoms,  231 
treatment,  241 
treatment,  operative,  prognosis  of, 

258 
treatment,  palliative,  260 
vaginal  hysterectomy  for,  246 
Warder's  operation  for,  252 
of  vagina,  189 

treatment,  190 
of  vulva,  116 

treatment,  118 
srjuamous-cell,  of  cervix,  226 
Caruncle,  urethral,  in 
diagnosis,  in 
treatment,  113 
Carunculse  myrtiformes,  92 
Catgut,    cumol,    preparation    of,    593, 

594 
formalin,  preparation  of,  595 
or  silk,  choice  of,  for  suture  and  liga- 
ture material,  626 

Cathelin's  urinary  segregator,  534 

Catheter,  Skene's,  45 

Talley's  intra-uterine,  45 

Catheterization,  532 

after  plastic  operation,  661    , 

Cautery  knife,  53 

Celio-uretero-cystostomy  for  ureteral  fis- 
tula, 551,  554 


Celio-uretero-ureterostomy    for   ureteral 

fistulae,  551 
Cellulitis,   pelvic,  508.     See   also   Para- 
metritis. 
Cervicitis,  214 
Cervicovaginal  artery,  267 
Cervix,  abrasions  of,  206 
adenocarcinoma  of,  228 
adenoma  of,  malignant,  230 
amputation  of,  Hegar's  method,  210 
anomalies  of  development  in,  63 
arrested  development  of,  64 
atresia  of,  63 

acquired,  220 

acquired,  treatment,  220 

diagnosis,  63 

treatment,  64 
atrophy  and  superinvolution  of,  214 
carcinoma  of,  225 

Byrne's  operation,  255 

clinical  history,  231 

combined   vaginal   and   abdominal 
hysterectomy,  242 

diagnosis,  232 

diagnosis,   by   freezing  microtome, 
238 

diagnosis,  differential,  240 

etiology,  226 

Finsen  rays  for,  261 

hysterectomy,     combined     vaginal 
and  abdominal,  242 

hysterectomy,  vaginal,  246 

pathology,  226 

recurrence  after  operation,  258 

Roentgen  rays  for,  261 

squamous-cell,  226 

symptoms,  231 

treatment,  241 

treatment,  operative,  prognosis  of, 
258 

treatment,  palliative,  260 

vaginal  hysterectomy  for,  246 

Werder's  operation,  252 
cardinal  ligaments  of,  269 
chancroid  of,  treatment,  218 
dilatation  of,  and  curettage  of  uterine 

cavity,  645 
discission  of,  for  version,  309 
diseases  of,  198 


668 


Index 


Cervix,  ectropion  of,  202 
endothelioma  of,  229 
epithelioma  of,  226 
erosion  of,  202,  214 

treatment,  215 
fibroid  polyps  of,  225 
hydatidiform  sarcoma  of,  261 
prognosis,  263 
symptoms,  262 
treatment,  262 
hypertrophy  of,  64 

treatment,  65 
injuries  of,  198 
lacerations  of,  201 

Emmet's  operation,  208 
Hegar's  operation,  210 
Pouey's  operation,  212 
Schroeder's  operation,  212 
Simon's  operation,  209 
treatment,  206 
malignant  adenoma  of,  230 
mobility  of,  269 
myomata  of,  221 
symptoms,  222 
treatment,  222 
new-growths  of,  221 
polyps  of,  222 
symptoms,  225 
treatment,  225 
relations  of,  to  ureter,  523 
rodent  ulcer  of,  218 
squamous-cell  carcinoma  of,  226 
stellate,  203 

transverse  ligaments  of,  269 
tuberculosis  of,  218 

treatment,  219 
ulceration  of,  218 
Chancroid  of  cervix,  treatment,  218 
Cleveland's  dilator,  587 
Clitoridectomy,  123 
Clitoris,  92 

diseases  of,  122 
hypertrophy  of,  72 
tumors  of,  123 
Coccygectomy,  130 
Coccygodynia,  89,  125 
diagnosis,  129 
etiology,  126 
pathological  anatomy,  126 


Coccygodynia,  symptoms,  129 

treatment,  130 
Collin's  speculum,  30 
Colloid  cancer  of  ovary,  479 
Colpitis,  137 
dissecting,  138 
emphysematosa,  138 

treatment,  140 
gonorrheal,  treatment,  138 
gummosa,  137 
treatment,  138 
Colpocleisis  for  urinary  fistulae,  54S 
Colpohyperplasia  cystica,  138 

treatment,  140 
Colporrhaphy,    anterior,    Martin's,    for 

prolapse,  304 
Colpo-uretero-cystostomy    for    ureteral 

fistulte,  551 
Condylomata,  pointed,  98 
of  vagina,  190 
of  vagina,  treatment,  192 
Congestion,  ovarian,  453 
Constrictor  vaginae  muscle,  135 
Corpora  albicantia,  448 

fibrosa,  448 
Corpus  luteum,  448 
cyst,  456 
uteri,  mobility  of,  269 
Crown  stitch,  183 

suture,  177 
Cumol  gut,  preparation  of,  593,  594 
Cuneohysterectomy,  293 
Curet,  Martin's,  587 

Sims',  39 
Curettage    in    fibromyoma   of    uterus 
340 
of   uterine    cavity,  and    dilatation    of 
cervix,  645 
Cylindrical  speculum,  36 

method  of  introducing,  37 
Cyst,  corpus  luteum,  456 
of  labium  majus,  105 
of  parametrium,  echinococcus,  516 
ovarian,  echinococcus,  504 
inflammation  of,  489 
papillary,  treatment,  503 
papillomatous  growths  in,  472 
j)unrture  of,  496 
removal  of,  497 


Index 


669 


Cyst,  ovarian,  rupture  of,  4S8 
simple  serous,  464 
suppuration  of,  489 
treatment,  495 
Cystadenoma  of  ovary,  465.     See  also 

Ovary,  cystadenoma  of. 
Cystic  degeneration  in  fibromyoma  of 
uterus,  329 

ovaries,  454,  461 
Cystitis,  535 

diagnosis,  537 

gonorrheal,  537 

membranous,  536 

symptoms,  537 

treatment,  538 

tuberculous,  537 

varieties,  536 
Cystocele,  Hirst's  operation,  166 

Martin's  operation,  169 

Stoltz's  operation,  169 

treatment,  163 
Cystoscope,  Eisner's,  529,  532 

Nitze,  527,  528 
Cystoscopy,  527 
Cysts  of  groins,  105 

of  labia,  105 

of  vagina,  185 
treatment,  187 

of  vestibule,  105 

parovarian,  484 


Davidson's  syringe,  43 

Dermoids    of   ovary,    474.         See    also 

Ovary,  dermoid  of. 
Diet  in  abdominal  section,  649 
Dietl's  crisis,  567 
Dilatation  of  cervix,  and  curettage   of 

uterine  cavity,  645 
Dilator,  Cleveland's,  587 

Goodell's,  587 

Wathen's,  587 
Diphtheritic  endometritis,  358 
Discus  proligerus,  446 
Dissecting  colpitis,  138 
Double  uterus,  59 

vagina,  69 
Douche,  Fritsch's  intra-uterine,  45 

pan,  44 


Douches,  vaginal,  43 
Douglas's  pouch,  264 
Downes'       electrothermic      hemostatic 

clamp,  592 
Drainage  in  abdominal  section,  633 
Drainage-tube  forceps,  639 
Dressings,  preparation  of,  591 
Duck-bill  speculum,  36 
Dudley's    operation  for    anteflexion  of 
uterus,  293 
for  ureteral  fistulae,  553 
Dysmenorrhea,  385 

etiology,  385 

membranous,  388 

symptoms,  386 

treatment,  387 


EcARTEUR,  247 

Echinococcus  cyst  of  ovary,  504 
of  parametrium,  516 

of  Fallopian  tubes,  412 
Ectopic     pregnancy,     426.       See     also 

Pregnancy,  extra-uterine. 
Ectropion  of  cervix,  202 
Edebohls'  kidney  air-cushion,  570 

method  of  nephrorrhaphy,  569 

self-retaining  speculum,  36 
Edema,  fibromyoma  of  uterus  and,  328 
Egg  cords,  445 
Electricity  in  treatment,  50 
Electrocautery  point,  590 
Elephantiasis  of  vulva,  no 
Elliot's  cotton  forceps,  40 
Eisner's  cystoscope,  529,  532 
Embryo,     death    of,     in    extra-uterine 

pregnancy,  433 
Emmet's  curet  forceps,  39 

operation  for  lacerated  cervix,  208 
for  restoring  pelvic  floor  and  nar- 
rowing vagina,  178 
Enchondroma  of  ovary,  483 
Endocervicitis,  216 

gonorrheal,  216 
treatment,  217 
Endometritis,  355 

diphtheritic,  358 

exfoliative,  388 

gonorrheal,  355 


6/0 


Index 


Endometritis,     gonorrheal,     symptoms, 
358 
treatment,  359 
hyperplastic,  chronic,  361 

chronic,  intermenstrual  pain  in,  363 
chronic,  symptoms,  362 
chronic,  treatment,  363 
infectious,  acute,  358 
acute,  symptoms,  358 
acute,  treatment,  358 
septic,  355 
syphilitic,  357 
tuberculous,  357 
Endometrium,  264,  266 

adenocarcinoma    of,    364.      See    also 

Adenocarcinoma  of  endometrium. 
diseases  of,  355 

inflammation  of,  355.      See  also  En- 
dometritis. 
influence  of  fibromyoma  in,  332 
myxomatous  polyps  of,  373 
neoplasms  of,  364 
sarcoma  of,  370 
Endosalpingitis,    closure   of  abdominal 

ostium  of  tube  from,  401 
Endothelioma  of  cervix,  229 
of  corpus  uteri,  372 
of  ovary,  482 
Epithelioma  of  cervix,  226 
Epoophoron,  447 
Erosion  of  cervix,  203,  214 

treatment,  215 
Eversion  of  cervix,  202 
Examination,  17 
backache  in,  18 

exploration  of  uterine  cavity  in,  39 
in  erect  posture,  25 
in  knee-chest  position,  32 
in  Sims'  position,  32 
keeping  notes  of  cases,  41 
leukorrhea  in,  17 
menstruation  in,   17 
mensuration  of  abdomen  in,  38 
objective  symptoms  in,  19 
of  abdomen,  37 

of  pelvic  organs  and  abdomen,  28 
pain  in,  17 
palpation  in,  19 
palpation  of  abdomen  in,  26 


Examination,   percussion  and  ausculta- 
tion of  abdomen  in,  38 

subjective  symptoms  in,  17 
Extra-uterine  pregnancy,  392,  426.    See 

also  Pregnancy,  extra-uterine. 


Fallopian  tubes,  392 

actinomycosis  of,  412 

anatomy  of,  392 

anomalies  of,  54 

blood-vessels  of,  393 

congestion  of,  394 

diseases  of,  394 

diseases  of,  symptoms,  413 

displacements  of,  395 

echinococcus  of,  412 

inflammation  of,   395.        See  also 

Salpingitis. 
lymphatics  of,  393 
neoplasms  of,  412 
nerves  of,  393 
syphilis  in,  411 
tuberculosis  of,  409 
Farre's  line,  445 
Fatty   degeneration   in   fibromyoma   of 

uterus,  328 
Fecal  fistula  following   abdominal  sec- 
tion, 658 
in  vagina,  192 
in  vagina,  symptorr.s,  193 
in  vagina,  treatment,  194 
Femoral  thrombophlebitis  following  ab- 
dominal section,  659 
Fetus,   death  of,   growth  and  develop- 
ment of  placenta  after,  437 
in  extra-uterine  pregnancy,  growth  of, 
after  third  month,  435 
Fibroid  polyps  of  cervix,  225 

recurrent,  of  uterus,  354 
Fibroma  of  ovary,  481 

of  vagina,  187 
Fibromyoma  of  parametrium,  514.    See 
also  Parametrium,  fihromyoma  of. 
of    uterus,  316 

amputation    of    subperitoneal    pe- 
dunculated tumors  for,  349 
amyloid  degeneration  in,  328 
Apostoli's  treatment,  339 


Index 


671 


Fibromyoma     of    uterus,    atrophy    of, 

332 

calcification,  330 

clinical  history,  ;^^;^ 

curettage  in,  340 

cystic  degeneration  in,  329 

degenerative  changes  in,  328 

diagnosis,  t,t,t„  336 

diagnosis,  differential,  from  preg- 
nancy, 337 

edema  and,  328 

electricity  in,  339 

enucleation  of,  by  abdominal  sec- 
tion, 347 

enucleation  of  submucous  tumors 
for,  343 

etiology,  316 

fatty  degeneration  in,  328 

heart  and,  324 

histology,  316,  326 

hysterectomy  for,  abdominal,  343 

hysterectomy  for,  vaginal,  349 

influence  on  endometrium,  332 

influence  upon  uterine  appendages, 

332 
intra -uterine  applications  for,  341 
ligation  of  uterine  arteries  for,  342 
malignant  degeneration  of,  332 
myomectomy  for,  349 
myxomatous  degeneration  in,  329 
necrobiosis  of,  330 
necrosis  of,  331 
panhysterectomy  for,  345 
pathologic  anatomy,  316 
pathologic  changes  in,  328 
pregnancy  and  differentiation,  337 
removal  of  myomatous  polyps  for, 

342 
salpingo-oophorectomy  for,  341 
shape,  318 
symptoms,  333 
thrombosis  in,  328 
treatment,  338 
treatment,  Apostoli's,  339 
treatment,  electrical,  339 
treatment,  hygienic,  339 
treatment,  medicinal,  339 
treatmeni,  palliative,  338 
treatment,  radical,  342 


Fibromyoma     of     uterus,      treatment, 
radical,  indications  for,  351 
uterine  appendages  in,  324 
Finsen  rays  for  carcinoma  of  cervix,  261 
Fistula.      See   Fecal,   urinary,   ureteral, 

etc. 
Floating  kidney,  566 

Dietl's  crisis  in,  567 
etiology,  566 
nephrorrhaphy  for,  569 
support  of,  by  operative  treatment 
of    diastasis    of    recti    muscles, 

574 
symptoms,  567 
symptoms,  objective,  567 
symptoms,  subjective,  567 
treatment,  568 
treatment,  operative,  569 
treatment,  palliative,  569 
Folliculoma  malignum  of  ovary,  483 
Folsom's  nasal  speculum,  Skene's  modi- 
fication, 559 
Forceps,  Allis',  5  88 
catch,  248 

for  wall  of  cystic  tumor,  592 
drainage-tube,  639 
Elliot's,  40 
Emmet's,  39 

for  removing  cervical  stitches,  662 
Thomas'  uterine,  48 
Foreign  bodies  in  uterus,  315 

in  vagina,  192 
Formalin  catgut,  preparation  of,  595 
Fountain  syringe,  43 
Fritsch's  intra-uterine  douche,  45 

urethral  canula,  557 
Fundus,  mobility  of,  269 


Gangrene  of  vulva,  99 
Garrulity  of  vulva,  149 
Gartner's  canal,  447 
Gehrung's  pessary,  165 

method  of  inserting,  165 
Genital  tract,  anomalies  of  development 
in,  54 

atresia  of,  74 

retention     of    mucus     and     blood 
within,  74 


6;2 


Index 


Genital  tract,   retention  of  mucus  and 

blood  within,  treatment,  78 
Glands,  Bartholin's,  92 
Globe  pessary,  165 
with  stem,  303 
Glove,  rubber,  for  examination,  22 
Gloves  of  surgeon,  preparation  of,  602 
Goddard  pessary,  304 
Gonorrheal  colpitis,  treatment,  138 
endocervicitis,  216 

treatment,  217 
endometritis,    355.     See    also    Endo- 
metritis, gonorrheal. 
macules,  94 
vulvitis,  93 
treatment,  95 
Goodell's  dilator,  587 

speculum,  30 
Gowns  of  surgeon,  preparation,  602 
Graafian  follicle,  446 
Groins,  benign  tumors  of,  105 

cysts  of,  105 
Gynecic  surgery,  detailed  technic  of,  577 
preliminary  treatment   and  exam- 
ination of  patient,  596 
Gynecological    examination,     17.      See 
also  Examination. 


HEMATOMA  ovarii,  456 

Hand  and  skin  cleansing,  598 

Harris'    instrument    for    collection    of 

urine,  533 
Heart,  fibromyoma  of  uterus  and,  324 
Hegar's  amputation  of  cervix,  210 
operation  for  prolapse  of  uterus,  305 
for  restoring  pelvic  floor  and  nar- 
rowing vagina,  185 
Hematocele,  ante-uterine,  437 
in  abdomen,  437 
pelvic,  437,  520 
symptoms,  520 
terminations,  520 
treatment,  521 
retro-uterine,  437 
Hematocolpos,  75 
Hematoma,  abdominal,  437 
pelvic,  437,  512 
pelvic,  treatment,  573 


Hematometra,  75,  220 
Hematosalpinx,  75,  220,  409 
Hemelythrometra,  75 
Hemorrhage  in  extra-uterine  pregnancy, 
434 
ovarian,  456.    See  also  Ovarian  hem- 
orrhage. 
pelvic,  512 

secondar}',  after  plastic  operation,  661 
in  abdominal  section,  650 
Hermaphroditism,  79 
Hernia,    abdominal,    as   secjuel   of   ab- 
dominal section,  655 
ovarian,  451 
pudendal,  122 

pudendal,  treatment  of,  122 
Hirst's  operation  for  cystocele,  166 
Hodge  pessary,  279 
Hydatid  of  Morgagni,  394 
Hydatidiform  sarcoma  of  cervix,  261 
of  cervix,  prognosis,  263 
of  cervix,  symptoms,  262 
of  cervix,  treatment,  262 
Hydrocele  of  round  ligament,  114 
Hydrometra,  220 
Hydrops  tubas  profiuens,  408,  413 
Hydrosalpinx,  220,  406 
Hymen,  92 
V  anomalies  of,  73 
Hyperplasia  of  vulva,  72 
Hypertrophy  of  cervix,  64 
treatment,  65 
of  clitoris,  72 
of  vulva,  72 
Hysteralgia,  315 

Hysterectomy,     abdominal,     for    fibro- 
myoma of  uterus,  343 
combined     vaginal     and     abdominal 
methods,  for  carcinoma  of  cervix, 
242 
for  inversion  of  uterus,  310 
vaginal,  for  carcinoma  of  cervix,  246 

for  fibromyoma  of  uterus,  349 
with  salpingectomy,  for  salpingitis,  424 


Impregnation     after     transplantation, 

504 
Infantile  uterus,  57 


Index 


^n 


Inflammation  of  ovary,  459.     See  also 

Oophoritis. 
Injuries  of  cervix,  198 
of  pelvic  floor,  145 
diagnosis,  151 
treatment,  161 
of  vagina,  131,  145 
diagnosis,  151 
treatment,  161 
of  vulva,  89 

to     levator    ani    muscle,     secondar}' 
perineorrhaphy  for,  176 
Instruments,  586 
preparation  of,  586 
special,  589 
Interstitial  pregnancy,  432 

abdominal  section  for,  442 
symptoms,  439 
termination,  436 
Intra-uterine  applications,  48 
injections,  44 
syringe,  48 
tamponade,  49 
Inversion  of  uterus,  270,  306 
diagnosis,  306 
diagnosis,  differential,  307 
discission  of  cervix  for,  309 
etiology,   306 

from  polyp,  treatment,  310 
hysterectomy  for,  310 
pressure  for,  308 
reduction  by  taxis,  307 
symptoms,  306 
treatment,  307 
treatment,  operative,  309 


JuNG-HoBEL  freezing  microtome,  238 


Kangaroo-tendon,  593 
Kelly's  knife-blade  tenaculum,  50 
Kidney,  anatomy,  522 
examination  of,  535 
floating,  566 

Dietl's  crisis  in,  567 
etiology,  566 
nephrorrhaphy  for,  569 
43 


Kidney,  floating,  support  of,  by  oper- 
ative treatment  of  diastasis  of 
recti  muscles,  574 

symptoms,  567 

symptoms,  objective,  567 

symptoms,  subjective,  567 

treatment,  568 

treatment,  operative,  569 

treatment,  palliative,  569 
Knee-chest  position,  32 
Knife,  cautery,  53 
Kraurosis  vulvje,  103 

etiology,  104 

prognosis,  105 

symptoms,  103 

treatment,  104 
Kuster's  sign,  493 


Labia,  benign  tumors  of,  105 
cysts  of,  105 
majora,  90 
minora,  90 
phlegmon  of,  99 
Labium  majus,  cyst  of,  105 
Laceration  of  cervix,  201 

Emmet's  operation,  208 
Hegar's  operation,  210 
Pouey's  operation,  212 
Schroeder's  operation,  212 
Simon's  operation,  209 
treatment,  206 
of  pelvic  floor,  treatment,  169 
of  perineum,  treatment,  169 
Lactation  atrophy,  313 
Lateroflexion,  270 
Lateroversion,  270 
Leukocyte-count  in  abdominal  section, 

651 
Levator  ani  muscle,  134 

injury    to,    secondary    perineor- 
rhaphy for,  176 
Ligament,     round,     hydrocele    of    the, 

114 
Ligature  material,  choice  of,  626 
Ligatures  and  sutures,  593 
Lupus  vulvae,  115 

treatment,  116 
Lymphatics  of  uterus,  268 


674 


Index 


Mackenrodt's   operation   for  ureteral 

fistula,  553 
Malignant  degeneration  in  fibromyoma 

of  uterus,  332 
Martin's  anterior  colporrhaphy  for  pro- 
lapse of  uterus,  304 

curet,  587 

operation  for  cystocele,  169 
Membrana  granulosa,  446 
Menopause,  378 

medical  management,  380 
Menorrhagia,  384 

atmokausis  for,  385 

treatment,  385 

zestokausis  for,  385 
Menstrual  molimina,  376 
Menstruation,  373 

absence  of,  381.   See  also  Amenorrhea. 

and    evolution,  connection    between, 

379 

cessation,  375,  378 

character  of  flow,  377 

definition,  373 

disorders  of,  355 

duration  of  flow,  378 

from  other  mucous  membranes,  384 

increased,  384 

interval  between  discharges,  378 

mechanism  of,  377 

medical  management,  380 

molimina  of,  376 

onset,  375 

painful,  385.    See  also  Dysmenorrhea. 

prolonged,  384 

quantity  of  flow,  378 

stages  of,  374 

symptoms,  376 

uterus  in,  375 

vicarious,  384 
Metritis,  310 

acute,  310 

treatment,  311 

chronic,  311 
symptoms,  311 
treatment,  312 
Microtome,  freezing,  diagnosis  of  car- 
cinoma of  cervix  by,  238 
Mittelschmerz,  363 
Mons  veneris,  90 


Morgagni,  hydatid  of,  394 
Mucus  and  blood,  retention  of,  within 
genital  tract,  74 
retention   of,   within  genital  tract, 
treatment,  78 
Muscle,  bulbocavernosus,   135 
levator  ani,  134 

injury    to,    secondary    perineor- 
rhaphy for,  176 
of  urogenital  trigonum,  135 
Myomata  of  cervix,  221 
symptoms,  222 
treatment,  222 
Myomectomy  for  fibromyoma  of  uterus, 

349 

Myometrium,  264,  265 

inflammation  of,  310.    See  also  Metri- 
tis. 

Myxomatous     degeneration     in     fibro- 
myoma of  uterus,  329 


Necrobiosis  in  fibromyoma  of  uterus, 

33° 
Necrosis  in  fibromyoma  of   uterus,  331 

of  ovary,  459 
Neoplasms  of  bladder,  540 

of  endometrium,  364 

of  Fallopian  tubes,  412 

of  ovary,  463.     See  also  Ovary,  neo- 
plasm of. 

of  parametrium,  514,  576 

of  urethra,  559 

of  uterus,  316 
Nephrectomy  for  ureteral  fistula,  551 
Nephrorrhaphy,  569 

Edebohls'  method,  570 

for  floating  kidney,  569 
Nephro-ureterectomy,  576 
Neuralgia  of  uterus,  315 
Nitze's  cystoscope,  527,  528 
Noma,  99 

Nott's  vaginal  depressor,  32 
Nullipara,  prolapsus  uteri  in,  296 


Oophorectomy  for  chronic  oophoritis, 

462 
Oophoritis,  acute,  etiology,  459 


Ind 


ex 


675 


Oophoritis,  acute,  pathogenesis,  459 

symptoms,  460 

treatment,  460 
chronic,  461 

diagnosis,  462 

etiology,  461 

oophorectomy  for,  462 

symptoms,  462 

treatment,  462 
Operating  room,  577 
table,  582,  585 

portable,  583,  584 
Osteoma  of  ovary,  483 
Ovarian  artery,  267,  268 

ligation  of,  in  fibromyoma,  342 
congestion,  453 
cysts,      papillomatous      growths     in, 

472 
hemorrhage,  456 

diffuse,  456 

follicular,  456 

interstitial,  456 

symptoms,  456 

treatment,  457 
hernia,  451 
pregnancy,  clinical  history,  432 

termination,  435 

treatment,  443 
Ovariocele,  451 
Ovary,  actinomycosis  of,  461 

adenoma  of,  implantation  metastases 

of,  503 
adhesions  of,  treatment,  499 
and  tube,  topographic  relation,  446 
anomalies  of,  54 
arteries  of,  446 
atrophy  of,  458 
carcinoma  of,  479 

colloid,  479 
cyst  of,  echinococcus,  504 

inflammation  of,  489 

papillary,  treatment,  503 

papillomatous  growths  in,  472 

puncture  of,  496 

removal  of,  497 

rupture  of,  488,  502 

suppuration  of,  489 

treatm.ent,  495 
cystadenoma  of,  pseudomucin,  465 


Ovary,   cystadenoma  of,  pseudomucin, 
pathologic  histology,  466 
serous,  471 
cystic,  454,  461 
definition,  445 
dermoid  of,  474 

clinical  history,  476 
etiology,  478 
frequency,  476 
rupture  of,  477 
diseases  of,  445 
displacements  of,  448 
echinococcus  cysts  of,  504 
enchondroma  of,  483 
endothelioma  of,  482 
fibroma  of,  481 
folliculoma  malignum  of,  483 
foreign  bodies  in,  504 
function,  447 
inflammation     of,     459.        See     also 

Oophoritis. 
lymphatics  of,  446 
necrosis  of,  459 
neoplasms  of,  463 
chnical  history,  486 
diagnosis,  490 
examination,  491 
infected,  removal,  502 
inflammation  of,  489 
malignant,  treatment,  503 
other  ovary  in,  503 
ovulogenous,  474 
rupture  of,  488 
stromatogenous,  481 
suppurating,  removal,  502 
suppuration,  489 
symptoms,  490 
treatment,  495 
twisted  pedicle  of,  487 
twisted  pedicle  of,  treatment,  501 
uterus  in,  503 
nerves  of,  446 
osteoma  of,  483 

other,  in  ovarian  neoplasms,  503 
prolapse  of,  449.     See  also  Prolapsus 

ovarii. 
relations  of,  to  ureter,  522 
sarcoma  of,  482 
simple  serous  cysts  of,  464 


6-]^^ 


Index 


Ovary,  stricture,  445 

supporting  ligaments  of,  447 

teratoma  of,  474,  479 

transplantation  of,   504 

tuberculosis  of,  460 
primary,  459 

veins  of,  446 
Ovulation,  447 

and    menstruation,     connection    be- 
tween, 379 
Ovulogenous  ovarian  tumors,  474 
Ovum,  446 


Palm.«  plicatcB,  201 

Panhysterectomy    for    adenocarcinoma 
of  endometrium,  369 
for  fibromyoma  of  uterus,  345 
Paracolpitis,  138 
Parametritis,  508 
chronic,  510 

treatment,  511 
etiology,  508 

organized  exudate,  treatment,  510 
symptoms,  508 
treatment,  509 
Parametrium,  264,  265 
actinomycosis  of,  517 
echinococcus  cysts  of,  516 
fibromyoma  of,  514 

differential  diagnosis,  514 
treatment,  515 
hemorrhage  from,  512 
injuries  of,  511 
neoplasms  of,  514,  516 
Paravaginitis,  treatment,  140 
Paroophoron,  447 
Parovarian  cysts,  484 
Parovarium,  447 

Pelvic  connective  tissue,  506.     See  also 
Parametrium. 
floor,  injuries  of,  145 

injuries  of,  diagnosis,  151 
injuries  of,  treatment,  161 
lacerations  of,  treatment,  169 
hematocele,  520.     See  also  Hemato- 
cele, pelvic. 
hematoma,  512 
peritonitis,  519 


Pelvic  peritonitis,  acute,  519 
acute,  treatment,  519 
venous     plexuses,     relations     of,     to 
ureter,  522 
Pelvis,  hematocele  in,  437 

hematomata  in,  437 
Perimetrium,  264 

Perineal  tear,  median,  secondary  opera- 
tion for,  170 
Perineorrhaphy,  secondary,  169 

for  complete  tear  of  perineum,  170 
for  injury  to  levator  ani  muscle,  176 
for   overstretching   and   subinvolu- 
tion of  vagina,  176 
for  rectocele,  176 
Perineum,  lacerations  of,  treatment,  169 
tear    of,    complete,    secondary    peri- 
neorrhaphy for,  170 
Perisalpingitis,   severance  of  adhesions 

from,  421 
Peritoneum,  diseases  of,  506 
inflammation  of,  519 
toilet  of,  in  abdominal  section,  628 
Peritonitis,  pelvic,  519 
acute,  519 

acute,  treatment,  519 
Pessaries,  contraindications,  281 
for  prolapse,  304 
for  retroversion,  279 
Gehrung's,  165 

method  of  inserting,  165 
globe,  165 

with  stem,  303 
Goddard's,  304 
Hodge,  279 
insertion  of,  182,  281 
left  in  vagina,  192 
Schultze,  165 
Smith,  279 
Thomas,  279 
Pfliiger's  tubes,  445 
Phleboliths,  518 
Phlegmon  of  labia,  99 
Phlegmonous    vaginitis,    treatment    of, 

140 
Physometra,  220 
Placenta,  growth  of,  after  fetal  death, 

437 
Placental  bruit,  38 


Index 


677 


Plastic  operation,  after-treatment,  660 
bowels  after,  661 
care  of  vulva  after,  661 
catheterization  after,  661 
confinement  to  bed  after,  663 
douches  after,  661 
gauze  packing  after,  660 
preparation  of  patient  for,  602 
removal  of  stitches  after,  661 
secondary  hemorrhage  after,  661 
technic  of,  642 

Polyps,  fibroid,  of  cervix,  225 
of  bladder,  540 
of  cervix,  222 
symptoms,  225 
treatment,  225 

Pouey's    operation    for    laceration    of 
cervix,  212 

Pregnancy,  abdominal,  clinical  history, 

433 

symptoms,  439 
broad-ligament,  435 
ectopic,    426.      See    also    Pregnancy, 

extra-uterine. 
extra -uterine,  426 

abdominal  section  for,  440 

advanced,  treatment,  443 

classification,  426 

clinical  history,  427 

death  of  embryo,  433 

death  of  fetus,  treatment,  443 

definition,  426 

diagnosis,  439 

etiology,  426 

frequency,  426 

growth  of  fetus  after  third  month, 

435 
hemorrhage  in,  434 
prognosis,  440 
rupture  of  sac  in,  434 
symptoms,  437 
symptoms,  objective,  438 
symptoms,  subjective,  437 
termination  of,  433 
treatment,  440 
treatment  after  rupture,  440 
uterus  in,  427 
vagina  in,  427 
fibromyoma  and,  differentiation,  337 


Pregnancy  in  one  horn  of   uterus  uni- 
cornis, 444 
in  one  part  of  uterus  bicornis,  444 
interstitial,  abdominal  section  for,  442 

clinical  history,  432 

symptoms,  439 

termination,  436 
ovarian,  clinical  history,  432 

termination,  435 

treatment,  443 
secondary,  437 

tubal,  abdominal  section  for,  technic, 
441 

clinical  history,  429 

pathology,  429 

termination,  436 

tubal  moles  after,  434 

vaginal  operation  for,  442 
tubo-abdominal,  437 
tubo-ovarian,  clinical  history,  432 
tubo-uterine,  termination,  436 
utero-abdominal,  clinical  history,  433 

pathology,  433 
Pressure  in  treating  inversion  of  uterus, 

308 
Prolapsus  ovarii,  449 

diagnosis,  449 

etiology,  449 

symptoms,  449 

treatment,  450 
uteri,  294 

clinical  history,  297 

diagnosis,  297 

etiology,  295 

Hegar's  operation,  305 

Martin's  anterior  colporrhaphy  for, 

304 

nuUipara,  296 

operation  for,  304 

pessaries  for,  304 

prognosis,  303 

reduction,  303 

symptoms,  297 

treatment,  303 

treatment,  operative,  304 

treatment,  operative,  statistics,  306 
Pruritus  vulvae,  100 

treatment,  loi 
Pseudohermaphroditism,  81 


678 


Index 


Pseudomyxoma  peritonei,  470 
Puberty,  373 

management,  380 
Pudendal  hernia,  122 

treatment,  122 
Pyometra,  220 
Pyosalpinx,  220 


Rectocele,  149 

secondary  perineorrhaphy  for,  176 
Recto-uterine  pouch,  264 
Rectovaginal  fistula  in  urinary  fistula, 

550 
Retractor,  abdominal,  586 

narrow-bladed  vaginal,  662 
Retroflexion,  270 
Retro-uterine  hematocele,  ,437 
Retroversion  of  uterus,  270 

Alexander's  operation,  284 

causes,  270 

chronic,  treatment,  274 

complicated     by     adhesions     and 
fixation,  treatment,  277 

diagnosis,  272 

from  accident,  treatment,  274 

in  puerperium,  treatment,  273 

pessaries  in  treatment,  279 

reposition  of  uterus,  275 

shortening  round  ligaments  for,  283 

shortening    utero-sacral    ligaments 
for,  283 

symptoms,  272 

treatment,  273 

treatment,  operative,  283 

treatment,  operative,  results,  291 

uterine  suspension  for,  288 
Rodent  ulcer  of  cervix,  218 

of  vulva,  114 

of  vulva,  prognosis,  115 

of  vulva,  treatment,  115 
Roentgen  rays  for  carcinoma  of  cervix, 

261 
Room,  operating,  577 
Round  ligament,  hydrocele  of,  114 

intraperitoneal  shortening  of,  283 

relations  of,  to  ureter,  524 

shortening   of,    Alexander's   opera- 
tion, 284 


Rubber  gloves  for  examination,  22 
Rudimentary  uterus,  56 
Rupture  of  ovarian  cyst,  502 
tumor,  488 


Salpingectomy  by  abdominal  route  for 

salpingitis,  422 
with  hysterectomy  for  salpingitis,  424 
Salpingitis,  395 

choice  of  operations,  424 

etiology,  395 

hysterectomy  with  salpingectomy,  424 

internal  massage  for,  419 

interstitial,  403 

interstitialis  disseminata,  403 

nodosa  isthmica,  403,  406 

nodosa  isthmica,  diagnosis,  415 

pathologic  anatomy,  396 

pseudofollicularis  cystica,  399 

salpingectomy    by    abdominal    route 

for,  422 
salpingostomy   after   abdominal   sec- 
tion for,  422 
severance  of  adhesions,  and  repositioa 

of  tubes  by  abdominal  route,  421 
symptoms,  413 
treatment,  415 
treatment,  curative,  420 
treatment,  operative,  420 
treatment,  palliative,  416 
treatment,  preventive,  415 
tubercular,  409 
Salpingo-oophorectomy  for  fibromyoma 

of  uterus,  341 
Salpingostomy,  after  abdominal  section,. 

for  salpingitis,  422 
Salt    solution    in  shock   of  abdominal 

section,  655 
Sarcoma,  hydatidiform,  of  cervix,  261 

of  cervix,  prognosis,  263 

of  cervix,  symptoms,  262 

of  cervix,  treatment,  262 
of  cervix,  hydatidiform,  261 
of  endometrium,  370 
of  ovary,  482 
of  uterus,  353 
of  vagina,   188 

treatment,  190 


Ind 


ex 


679 


Sarcoma  of  vulva,  119 

Scarificator,  Buttle's,  50 

Schede's  operation  for  ureteral  fistula, 

552 
Schroeder's  operation  for  laceration  of 

cervix,  212 
Schultze's  pessary,  165 
Shock,     treatment    of,     in     abdominal 

section,  654 
Silk  or  catgut,  choice  of,  for  suture  and 
ligature  material,  626 

preparation  of,  595 
Simon's  operation  for  lacerated  cervix, 

209 
Simpson's  uterine  sound,  40 
Sims'  position,  32 

sharp  curet,  39 

speculum,  32 

speculum,  method  of  introducing,  31, 

36  _ 

Sinus  following  abdominal  section,  658 

urogenital,  arrested  development,  71 
Skene's  fissure  probe  and  knife,  559 
modification  of  Folsom's  nasal  specu- 
lum, 559 
reflux  catheter,  45 
urinal  cup-pessary,  556 
Skin,  cleansing  of,  598 
Smith  pessary,  279 

Speculum,  bivalve,  method  of  introduc- 
ing, 29 
Colhn's,  30 
cylindrical,  36 

method  of  introducing,  37 
duck-bill,  36 

Edebohls'  self-retaining,  36 
Folsom's,  Skene's  modification,  559 
Goodell's,  30 
Sims',  32 

method  of  introducing,  31,  36 
skeleton  bivalve,  30 
Squamous-cell  carcinoma  of  cervix,  226 
Stellate  cervix,  203 
Stenosis,  acquired,  of  vagina,  141 
of  vagina,  etiology,  142 
of  vagina,  symptoms,  142 
of  vagina,  treatment,  143 
Sterility,  35-,  389 
etiology,  389 


Sterility,  psychic  causes,  390 

treatment,  390 
Sterilizer,  office,  for  instruments,  20 
Sterilizers,  water,  580 
Stolz's  operation  for  cystocele,  169 
Stricture  of  urethra,  558 
Subinvolution  of  uterus,  312 
Superinvolution  of  uterus,  313 
Surgeon,  preparation  of,  602 
Suture,  crown,  177 

material,  choice  of,  626 
Sutures  and  ligatures,  593 
Syphilis  of  Fallopian  tubes,  411 

of  vulva,  121 
Syphilitic  endometritis,  357 
Syringe,  Braun's  intra-uterine,  48 

Davidson's,  43 

fountain,  43 


Table,  examining,   for  office  practice, 

20 
operating,  582,  585 

portable,  583,  584 
Talley's  intra-uterine  catheter,  45 
Tamponade,  intra-uterine,  49 
Tampons,  vaginal,  46 
Taxis  in  reducing  inversion  of  uterus, 

307 
Tenaculum,  Kelly's  knife-blade,  50 

Ulrich's,  545 
Teratoma  of  ovary,  474,  479 
Theca  foUiculi,  446 
Thermocautery,  589 

points,  590 
Thomas'  pessary,  279 

uterine  dressing  forceps,  48 
probe,  40 
Thrombophlebitis,     femoral,     following 

abdominal  section,  659 
Thrombosis  of  vessels  in  fibromyoma  of 

uterus,  328 
Torsion  of  uterus,  270 
Trendelenburg    posture    in    pelvic    and 

abdominal  operations,  617 
Trigonum,  urogenital,  muscle  of,  135 
Trimethylamin,   138 
Trocar  for  cystic  tumors,  592 
Tubal  abortion,  436 


6So 


Index 


Tubal  pregnancy,  429.     See  also  Preg- 
nancy, tubal. 
Tubercle  bacilli  in  urine,  537 
Tuberculosis  of  cervix,  218 
treatment,  219 
of  endometrium,  357 
of  Fallopian  tubes,  409 
of  ovary,  460 

primary,  459 
of  urethra,  565 
of  vagina,  141 

treatment,  141 
of  vulva,  115 
treatment,  116 
Tuberculous  endometritis,  357 
Tubo-abdominal  pregnancy,  437 
Tubo-ovarian   pregnancy,    clinical   his- 
tory, 432 
Tubo-uterine    pregnancy,    termination, 

436 
Tumors,  benign,  of  groins,  105 
of  labia,  105 
of  vestibule,  105 
clitoris,  123 
polyp  of,  inversion  from,  treatment, 

310 
polypoid,  of  cervix,  222 
of  cervix,  symptoms,  225 
of  cervix,  treatment,  225 
Twisted  pedicle  of  ovarian  tumor,  487 
of  ovarian  tumor,  symptoms,  487 
of  ovarian  tumor,  treatment,  487, 
501 


Ulcer,  rodent,  of  cervix,  218 
of  vulva,  114 
of  vulva,  prognosis,  115 
of  vulva,  treatment,  115 
Ulceration  of  cervix,  218 

of  vagina,  treatment,   140 
Ulrich's  tenaculum,  545 
Ureter,  anatomy,  522 
examination  of,  532 
palpation  of,  534 
relations  of  cervix  uteri  to,  523 
ovary  to,  522 

pelvic  venous  plexuses  to,  522 
to  bladder,  525 


Ureter,  relations  to  broad  ligament,  524 

to  round  ligament,  524 

to  ureter,  525 

to  vagina,  524 

uterine  ovary  to,  522 
surgical  injuries  of,  treatment,  551 
Ureteral  anastomosis  for  ureteral  iistulse, 

551 
fistula,  abdominal    operation  for,  553 
anastomosis  for,  551 
Bandl's  operation,  553 
celio-uretero-cystostomy    for,    551, 

554 
celio-uretero-ureterostomy  for,  551 
colpo-uretero-cystostomy  for,  551 
Dudley's  operation,  553 
Mackenrodt's  operation,  553 
nephrectomy  for,  551 
Schede's  operation,  552 
treatment,  551 
vaginal  operation,  552 
Van    Hook's  lateral    invagination, 

554 

Witzel's  treatment,  555 
Ureterectomy,  576 
Urethra,  anatomy,  526 
atresia  of,  556 

symptoms,  556 

treatment,  556 
defects  of,  556 

symptoms,  556 

treatment,  556 
dilatability  of,  560 

diagnosis,  561 

symptoms,  560 

treatment,  561 
dilatation  of,  560 

diagnosis,  561 

symptoms,  560 

treatment,  56r 
diseases  of,  556 
displacements  of,  562 
examination  of,  530 
fistula  of,  565 
foreign  bodies  in,  565 
granular  erosion  of,  558 
inflammation  of,  557 
malformation  of,  556 

symptoms,  556 


Index 


68 1 


Urethra,    malformation    of,    treatment, 

556 
mucous   membrane   of,   inversion   of, 

563 
mucous  membrane  of,  prolapse  of,  563 
mucous   membrane   of,    prolapse   of, 

causes,  563 
mucous   membrane   of,    prolapse   of, 

diagnosis,  564 
mucous   membrane   of,    prolapse   of, 

symptoms,  564 
mucous   membrane   of,    prolapse   of, 

treatment,  564 
neoplasms  of,  559 
partial  defect  of,  556 
sacculated,  560 
stricture  of,  558 
total  defect  of,  556 
tuberculosis  of,  565 
vesical  calculi  in,  565 
Urethral  canal,  duplicity  of,  556 
caruncle,  iii 
diagnosis,    in 
treatment,  113 
fistula,  565 
Urethralgia,  557 
Urethritis,  557 
Urethrocele,  560 
Urethroscope,  530 
Urinary  fistula,  541 

after-treatment,  550 
classification,  542 
colpocleisis  for,  548 
diagnosis,  544 
rectovaginal  fistula  in,  550 
serious     defect     of     bladder     and 

urethra,  550 
treatment,  544 
treatment,  operative,  545 
tract,  anatomy,  522 
diseases  of,  522 
examination  of,  522 
Urine,  tubercle  bacilli  in,  537 
Urogenital  sinus,  arrested  development 
of,  71 
trigonum,  muscle  of,  135 
Uterine    appendages     in    fibrotayoma, 

324 
influence  of  fibromyoma  on,  332 


Uterine  artery,  267 

relations  of,  to  ureter,  522 
cavity,  curettage  of,  and  dilatation  of 
cervix,  645 
exploration  of,  39 
repositor,  277 

suspension  for  retroversion,  288 
tubes,  392.    See  also  Fallopian  tubes. 
Utero-abdominal     pregnancy,     clinical 
history,  433 
pathology,.  433 
Uterosacral    ligaments,    shortening    of, 

283 
Uterus,  absence  of,  56 
anomalies  of,  55 
anteflexion  of,  270,  291 
anteposition  of,  291 
anteversion  of,  270,  291 
applications  into,  48 
arteries  of,  ligation  of,  in  fibromyoma, 

342 
atrophy  of,  313 
bicornis  duplex,  61 

pregnancy  in  one  horn  of,  444 
unicollis,  61 
bifid,  61 

blood-vessels  of,  267 
cordiformis,  61 
didelphys,  59 
diseases  of,  264 
displacements  of,  264,  270 
divisions  of,  264 
double,  59 

during  menstruation,  375 
endothelioma  of,  372 
fibromyoma  of,  316.     See  also  Fibro- 
myoma of  uterus. 
foreign  bodies  in,  315 
form,  264 

in  extra-uterine  pregnancy,  427 
in  ovarian  neoplasms,  503 
incudiformis,  62 
infantile,  57 
injections  into,  44 
injuries  of,  314 
injury  in  curetment,  314 
inversion  of,  270,  306.     See  also  In- 
version of  uterus. 
lateroflexion  of,  270 


68: 


Index 


Uterus,  lateroversion  of,  270 

ligaments  of,  268 

lymphatics  of,  268 

mobility  of,  269 

neoplasms  of,  316 

nerves  of,  268 

neuralgia  of,  315 

partitus,  62 

perforation  of,  314 

position  of,  269 

prolapse  of,  270,  294.     See  also  Pro- 
lapsus uteri. 

recurrent  fibroid  of,  354 

retroflexion  of,  270 

retroversion  of,  270.     See  also  Retro- 
version of  uterus. 

rudimentary,  56 

sarcoma  of,  353 

semi-partitus,  62 

septus,  62 

subinvolution  of,  312 

subseptus,  62 

superinvolution  of,  313 

supports  of,  268 

syringe  for,  48 

tamponade  of,  49 

torsion  of,  270 

unicornis,   57 

pregnancy  in  one  horn  of,  444 


Vagina,  absence  of,  65 

anomalies  of,  65 

atresia  of,  acquired,  141 
acquired,  etiology,  142 
acquired,  symptoms,  142 
acquired,  treatment,  144 

carcinoma  of,  189 
treatment,  190 

condylomata  of,  pointed,  190 
pointed,  treatment,  192 

cysts  of,  185 
treatment,  187 

diseases  of,  131 

double,  69 

fecal  fistula  in,  192 
symptoms,  193 
treatment,  194 

fibromata  of,  187 


Vagina,  foreign  bodies  in,  192 
in  extra -uterine  pregnancy,  427 
inflammation  of,  137 

treatment,  138 
injuries  of,  131,  145 

diagnosis,  151 

treatment,  161 
mucous  membrane  of,  applications  to, 

47 
new-growths  of,  185 
overstretching  and  subinvolution  of, 
secondary  perineorrhaphy  for,  176 
pessary  left  in,  192 
relations  of,  to  ureter,  524 
sarcoma  of,  188 

treatment,  190 
stenosis  of,  acquired,  141 
acquired,  etiology,  142 
acquired,  symptoms,  142 
acquired,  treatment,  143 
tuberculosis  of,  141 

treatment,  141 
ulcerations  of,  treatment,  140 
unilateral,  69 
Vaginal  douches,  43 
hernia,  122 

treatment  of,  122 
hysterectomy     for     fibromyoma     of 

uterus,  349 
operation  for  tubal  pregnancy,  442 
section,  technic  of,  640 
tampons,  46 
Vaginismus,  194 
treatment,  195 
Vaginitis,  137 

phlegmonous,  treatment,  140 
treatment,  138 
Van    Hook's    lateral    invagination    for 

ureteral  fistula,  554 
Varices  of  broad  ligament,  517 
Varicocele  of  broad  ligament,  517 

of  vulva,  no 
Venereal  warts,  97 
Vermiform    appendix,    examination   of,. 

in  abdominal  section,  626 
Vesical  calculus,  541 
Vesico-urethral  fissure,  559 
Vesico-uterine  pouch,  264 
Vestibule,  91 


Index 


683 


Vestibule,  benign  tumors  of,  105 

cysts  of,  105 
Vulva,  anomalies  of,  71 

atresia  of,  71 

carcinoma  of,  116 
treatment,  118 

care  of,  after  plastic  operation,  661 

development  of,  72 

diseases  of,  89 

elephantiasis  of,  no 

gangrene  of,  99 

garrulity  of,  149 

hyperplasia  of,  72 

hypertrophy  of,  72 

injuries  of,  89,  123 

lupus  of,  115 
treatment,  116 

rodent  ulcer  of,  114 
prognosis,  115 
treatment,  115 

sarcoma  of,  119 

sensory  nerve-supply  of,  92 

syphilis  of,  121 

tuberculosis  of,  115 


Vulva,  tuberculosis  of,  treatment,  116 

varicocele  of,  no 
Vulvitis,  92 

gonorrheal,  93 
treatment,  95 

treatment,  95 
Vulvovaginal  abscess,  96 

glands,  92 


Warts,  venereal,  97 

Water  sterilizers,  580 

Wathen's  dilator,  587 

Werder's    operation    for    carcinoma    of 

cervix,  252 
Witzel's  treatment  for    ureteral  fistula 

555 


Yellovv^  body,  448 


Zestokausis  for  menorrhagia,  385 


SAUNDERS*  BOOKS 


on 


Nervous  and  Mental 
Diseases,  Children, 
Hygiene,  Nursing,  and 
Medical  Jurisprudence 

W.  B.  SAUNDERS  &  COMPANY 

925  WALNUT  STREET  PHILADELPHIA 

NEW   YORK  LONDON 

Fuller  Building,  5th  Ave.  and  23d  St.  9.  Henrietta  Street,  Covent  Garden 

SAUNDERS'  SUCCESSFUL  PUBLISHING 

A  factor  of  no  little  moment  in  establishing  the  re- 
markable success  of  Saunders'  publications  is 
the  wide  publicity  given  them.  Besides  an  immense 
amount  of  circular  matter  constantly  being  distributed, 
the  Firm's  announcements  appear  in  practically  all  the 
leading  weekly  medical  journals  of  America  and  Eng- 
land ;  and  recently  there  has  been  added  to  the  list  the 
Indian  Lancet,  the  leading  medical  weekly  in  India. 
This  unprecedented  medical  publicity  really  means 
that  the  announcements  of  W.  B.  Saunders  &:  Com- 
pany are  weekly  placed  in  the  hands  of  120,000 
English-speaking  physicians. 

A  Complete  Catalogue  of  Our  Publications  will  be  Sent  upon  Request 


SAUNDERS'    BOOKS    ON 


Peterson  and  Haines* 
Legal  Medicine  6»  Toxicology 


A  Text=Book  of  Legal  Medicine  and  Toxicology.  Edited  by 
Frederick  Peterson,  M.  D.,  Clinical  Lecturer  on  Psychiatry  and 
Instructor  in  Neurology,  College  of  Physicians  and  Surgeons,  New 
York  ;  and  Walter  S.  Haines,  M.  D.,  Professor  of  Chemistry,  Phar- 
macy, and  Toxicology,  Rush  Medical  College,  in  affiliation  with  the 
University  of  Chicago.  Two  imperial  octavo  volumes  of  about  750 
pages  each,  fully  illustrated.  Per  volume  :  Cloth,  ^5.00  net ;  Sheep  or 
Half  Morocco,  $6.00  net.     Sold  by  Snbscription. 

AN   ENTIRELY   NEW   WORK— JUST   READY 

The  object  of  the  present  work  is  to  give  to  the  medical  and  legal  professions 
a  comprehensive  survey  of  forensic  medicine  and  toxicology  in  moderate  compass. 
This,  it  is  believed,  has  not  been  done  in  any  other  recent  work  in  English.  Under 
"  Expert  Evidence"  not  only  is  advice  given  to  medical  experts,  but  suggestions 
are  also  made  to  attorneys  as  to  the  best  methods  of  obtaining  the  desired  infor- 
mation from  the  witness.  An  interestmg  and  important  chapter  is  that  on  "  The 
Destruction  and  Attempted  Destruction  of  the  Human  Body  by  Fire  and  Chemi- 
cals." A  chapter  not  usually  found  in  works  on  legal  medicine  is  that  on  "  The 
Medicolegal  Relations  of  the  X-Rays."  This  section  will  be  found  of  unusual  im- 
portance. The  responsibility  of  pharmacists  in  the  compounding  of  prescriptions, 
in  the  selling  of  poisons,  in  substituting  drugs  other  than  those  prescribed,  etc., 
furnishes  a  chapter  of  the  greatest  interest  to  every  one  concerned  with  questions 
of  medical  jurisprudence.  Also  included  in  the  work  is  the  enumeration  of  the 
laws  of  the  various  states  relating  to  the  commitment  and  retention  of  the  insane. 

CONTRIBUTORS 


Samuel  T.  .Armstrong.  M.D.,  Ph.D.,  New  York. 
Pearce  Bailey,  .VI.D.',  New  York  Citv. 
Le^vis  Balch,  M.D.,  Ph.D.,  New  York  Citv. 
\V.  T.  Belfield,  M.D..  Chicago,  111. 
Chas.  Gilbert  Chaddock,  M.D.,  St.  Louis,  Mo. 
John  Chalmers  DaCosta,  M.D.,  Philadelphia. 
Joseph  F.  Darling.  A..M.,  LL.B.,  New  York. 
Edward  P.  Davis,  A..M.,  M.D.,  Philadelphia. 
Charles  .\.  Doremus,  M.D.,  Ph.D.,  New  York. 
W.  \.  Newman  Dorland,  M  D.,  Philadelphia. 
I.  T.  E.=;kridge,  .M.D.,  Denver,  Col. 
Marshall  D.  Ewell,  A.M.,  M.D..  LL.D.,  Chicago 


Charles  Harrington,  M.D.,  Boston,  Mass. 
Ludvig  Hektoen,  M.D.,  Chicago,  111. 
James  W.  Holland,  M.D.,  Philadelphia,  Pa. 
Reid  Hunt,  M.D.,  Ph.D.,  Baltimore,  Md. 
Edward  lackson,  A.M.,  M.D.,  Denver,  Col. 
Smith  Ely  Jelliffe,  A.M.,  M.D.,  Ph.D.,  N.  Y. 
Walter  Jones,  Ph.D.,  Baltimore,  Md. 
F.  W.  Langdon,  M.D.,  Cincinnati,  Ohio. 
Carlos  F.  MacDonald,  A.M.,  M.D.,  New  York. 
Harold  N.  Moyer,  M.D.,  Chicago,  111. 
Oscar  Oldberg,  Pharm.D.,  Chicago,  111. 
Frederick  Peterson,  M.D.,  New  York  City. 


James  Ewing,  M.D.,  New  York  City.  Albert  B.  Prescott,  M.D.,  LL.D.,  Ann  Arbor. 

Leonard   Freeman,  A.M.,  M.D.,  B.S.,  Denver.  |  Jerome  Probst,  Ph.G.,  LL.B.,  Chicago,  111. 
.A.  L.  Goldwater,  M.D.,  New  York  City.  '  Jerome  H.  Salisbury,  A.M.,  M.D.,  Cliicago. 

Walter  S.  Hames.  M.D..  Chicago,  111.  i  Allen  J.  Smith,  A.M.,  M.D.,  Galveston,  Te.\. 

Josiah  N.  Hall.  M.D.,  Denver,  Col.  j  Geo.  Knowles  Swinburne,  .A  B.,  M.D.,  N.  Y. 

Graeme  M.  Hammond,  LL.B.,  M.D.,  N.  Y.       '  Victor  C.  Vaughan,  M.D.,  LL.D.,  Ann  Arbor. 
Edward  S.  Wood,  A.M.,  M.D.,  Boston,  Mass. 


NERVOUS  AND   MENTAL    DISEASES. 


Church  and  Peterson's 
Nervous  and  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases  and  Head  of  Neurologic 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  President  New  York  State  Commission 
on  Lunacy;  Chief  of  Clinic,  Department  for  Nervous  Diseases,  College 
of  Physician  and  Surgeons,  New  York.  Handsome  octavo,  875  pages; 
322  illustrations.     Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  36.00  net. 

FOURTH    EDITION,  THOROUGHLY   REVISED— JUST   ISSUED 

This  work  has  met  with  a  most  favorable  reception  from  the  profession  at 
large,  four  editions  having  been  called  for  in  as  many  years.  It  fills  a  distinct 
want  in  medical  literature,  and  is  unique  in  that  it  furnishes  in  one  volume  prac- 
tical treatises  on  the  two  great  subjects  of  Neurology  and  Psychiatr}\  In  this 
edition  the  book  has  been  thoroughly  revised  in  every  part,  both  by  additions  to 
the  subject  matter  and  by  rearrangement  wherever  necessary,  to  make  it  more 
acceptable  to  the  practitioner  and  the  student.  Several  sections  have  been 
entirely  rewritten,  and  there  have  been  added  a  number  of  new  illustrations,  an 
increased  amount  of  tabular  matter,  and  a  series  of  diagrams  that  have  proved 
of  assistance  in  the  solution  of  diagnostic  problems. 


OPINIONS  OF  THE    MEDICAL   PRESS 


American  Journal  of  the  Medical  Sciences 

"  This  edition  has  been  revised,  new  illustrations  added,  and  some  new  matter,  and  really 
is  two  books.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
and  disputed  matters  and  theories  are  omitted.     Altogether  it  is  a  most  useful  text-book." 

Journal  of  Nervous  suid  Mental  Diseases 

"The  best  text-book  exposition  of  this  subject  of  our  day  for  the  busy  practitioner.  .  .  . 
The  chapter  on  idiocy  and  imbecility  is  undoubtedly  the  best  that  has  been  given  us  in  any 
work  of  recent  date  upon  mental  diseases.  The  photographic  illustrations  of  this  part  of  Dr. 
Peterson's  work  leave  nothing  to  be  desired." 

New  York  Medical  Journal 

"  To  be  clear,  brief,  and  thorough,  and  at  the  same  time  authoritative,  are  merits  that 
ensure  popularity.  The  medical  student  and  practitioner  will  find  in  this  volume  a  ready  and 
reliable  resource." 


SAUNDERS'  BOOKS   ON 


Barton  and  Well*/*' 
Medical  Thesaurus 

A   NEW   WORK— JUST   ISSUED 


A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  A.  M.,  Assistant  to  Professor  of  Materia  Medica  and  Thera- 
peutics, and  Lecturer  on  Pharmacy,  Georgetown  University,  Washing- 
ton, D.  C. ;  and  Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryn- 
gology and  Rhinology,  Georgetown  University,  Washington,  D.  C. 
•Handsome  octavo  of  about  650  pages.  Cloth,  $0.00  net;  Sheep  or 
Half  Morocco,  ^0.00  net. 

THE   ONLY   MEDICAL  THESAURUS   EVER   PUBLISHED 

This  work  is  the  only  Medical  Thesaurus  ever  pubHshed.  It  aims  to'  perform 
for  medical  literature  the  same  services  which  Roget'swork  has  done  for  literature 
in  general  ;  that  is,  instead  of,  as  an  ordinary  dictionary  does,  supplying  the 
meaning  to  given  words,  it  reverses  the  process,  and  when  the  meaning  or  idea 
is  in  the  mind,  it  endeavors  to  supply  the  fitting  term  or  phrase  to  express  that 
idea.  To  obviate  constant  reference  to  a  lexicon  to  discover  the  meaning  of 
terms,  brief  definitions  are  given  before  each  word.  As  a  dictionary  is  of  service 
to  those  who  need  assistance  in  interpreting  the  expressed  thought  of  others,  the 
Thesaurus  is  intended  to  assist  those  who  have  to  write  or  to  speak  to  give  proper 
expression  to  their  own  thoughts.  In  order  to  enhance  the  practical  application 
of  the  book  cross  references  from  one  caption  to  another  have  been  introduced, 
and  terms  inserted  under  more  than  one  caption  when  the  nature  of  the  term 
permitted.  In  the  matter  of  synonyms  of  technical  words  the  authors  have  per- 
formed for  medical  science  a  service  never  before  attempted.  Writers  and 
speakers  desiring  to  avoid  unpleasant  repetition  of  words  will  find  this  feature 
of  the  work  of  invaluable  service.  Indeed,  this  Thesaurus  of  medical  terms  and 
phrases  will  be  found  of  inestimable  value  to  all  persons  who  are  called  upon 
to  state  or  explain  any  subject  in  the  technical  language  of  medicine.  To  this 
class  belong  not  only  teachers  in  medical  colleges  and  authors  of  medical  books, 
but  also  every  member  of  the  profession  who  at  some  time  may  be  required  to 
deliver  an  address,  state  his  experience  before  a  medical  society,  contribute  to 
the  medical  press,  or  give  testimony  before  a  court  as  an  expert  witness. 


INSANITY  AND   HYGIENE. 


Brower  and  Bannister 
on  Insanity 

A  Practical  Manual  of  Insanity.  For  the  Student  and  General 
Practitioner.  By  Daniel  R.  Brower,  A.M.,  M.D.,  LL.  D.,  Professor 
of  Nervous  and  Mental  Diseases  in  Rush  Medical  College,  in  affiliation 
with  the  University  of  Chicago  ;  and  Henry  M.  Bannister,  A.  M., 
M.  D.,  formerly  Senior  Assistant  Physician,  Illinois  P^astern  Flospital 
for  the  Insane.  Handsome  octavo  of  426  pages,  with  a  number  of 
full-page  inserts.      Cloth,  ;^3.oo  net. 

FOR   STUDENT  AND   PRACTITIONER 

This  work,  intended  for  the  student  and  general  practitioner,  is  an  intelligible, 
up-to-date  exposition  of  the  leading  facts  of  psychiatry,  and  will  be  found  of  in- 
valuable service,  especially  to  the  busy  practitioner  unable  to  yield  the  time  for  a 
more  exhaustive  study.  The  work  has  been  rendered  more  practical  by  omitting 
elaborate  case  records  and  pathologic  details,  as  well  as  discussions  of  speculative 
and  controversial  questions. 

American  Medicine 

"  Commends  itself  for  lucid  expression  in  clear-cut  English,  so  essential  to  the  student  in 
any  department  of  medicine.  .  .  .  Treatment  is  one  of  the  best  features  of  the  book,  and  for 
this  aspect  is  especially  commended  to  general  practitioners." 

Bergey*s  Hygiene 

The  Principles  of  Hygiene:  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  A.  Bergey,  A.  M.,  M.D.,  First 
Assistant,  Laboratory  of  Hygiene,  University  of  Pennsylvania.  Octavo 
volume  of  495  pages,  illustrated.     Cloth,  ^3.00  net. 

FOR   STUDENTS.  PHYSICIANS,  AND    HEALTH   OFFICERS 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practices  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
The  book  is  based  on  the  most  recent  discoveries,  and  represents  the  practical 
advances  made  in  the  science  of  hygiene  up  to  date. 

Buffalo  Medical  Journal 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 


SACWBE/iS'    BOOK'S   ON 


GET  J^  •  THE  NEW 

THE  BEST  m\  m  6  r  1  C  Si  n  standard 

Illustrated   Dictionary 

Third  Revised  Edition — Just  Issued 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches  ;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octav^o,  nearly  800  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net;  with  thumb  index,  ^5.00  net. 

Gives  a  Mevximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 

Possible  Cost 

THIRD   EDITION    IN   THREE  YEARS  — 12.500  COPIES 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  i  ^ 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  one  hundred 
important  new  terms  that  have  appeared  in  recent  medical  literature  have  been 
added,  thus  bringing  the  book  absolutely  up  to  date.  The  book  contains  hun- 
dreds of  terms  not  to  be  found  in  any  other  dictionary,  over  100  original  tables, 
and  many  handsome  illustrations,  including  24  colored  plates. 


PERSONAL    OPINIONS 


Howard  A.  Kelly.  M.  D., 

Professor  of  Gynecology,  Johns  Hopkins  University ,  Baltimore. 

"  Dr.  Borland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Roswell  Park.  M.  D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery,  University  of 
Buffalo. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within  rela- 
tively small  space.  I  find  nothing  to  criticize,  very  much  to  commend,  and  was  interested  in 
finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries," 


PERSONAL   HYGIENE. 


Galbraith*s 
Four  Epochs  of  Woman's  Life 

Second  Revised  Edition — Just  Issued 


The  Four  Epochs  of  Woman's  Life:  A  Study  in  Hygiene.  By 
Anna  M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of 
Medicine,  etc.  With  an  Introductory  Note  by  John  H.  Musser,  M.D., 
Professor  of  Clinical  Medicine,  University  of  Pennsylvania.  i2mo 
volume  of  200  pages.     Cloth,  $0.00  net. 

MAIDENHOOD.  MARRIAGE,  MATERNITY.  MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive 
manner,  those  truths  of  which  every  woman  should  have  a  thorough  knowledge. 
Written,  as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped 
even  by  those  most  unfamiliar  with  medical  subjects. 

Birmingham  Medic&l  Review,  Eng[land 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public.     But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  wholesome.' 

Pyle*s  Personal  Hygiene 


A  Manual  of  Personal  Hygiene :  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pyle,  A.  M., 
M.  D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  344  pages,  fully  illustrated.     Cloth,  ^1.50  net. 

PROPER  LIVING   UPON   A   PHYSIOLOGIC   BASIS 

The  object  of  this  manual  is  to  set  forth  plainly  the  best  means  of  developing 
and  maintaining  physical  and  mental  vigor.  It  represents  a  thorough  exposition 
of  living  upon  a  physiologic  basis.  There  are  chapters  upon  Hygiene  of  the 
Digestive  Apparatus,  Skin  and  its  Appendages,  Vocal  and  Respiratory  Apparatus, 
Eye,  Ear,  Brain,  and  Nervous  System,  and  a  chapter  upon  Exercise. 

Boston  Medical  and  Surgical  Journal 

"  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers  have 
succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound  knowl- 
edge." 


SAC'.VDE/^S'  BOOK'S    OX 


Draper's  Leg(al  Medicine 

A  Text=Book  of  Legal  Medicine.  By  Frank  Winthrop  Draper, 
A.  ]\I.,  M.  D.,  Professor  of  Legal  Medicine  in  Harvard  University,  Bos- 
ton ;  Medical  Examiner  of  the  County  of  Suffolk,  Massachusetts,  etc. 
Handsome  octavo  volume  of  nearly  600  pages,  fully  illustrated.    Cloth, 

So.oo  net. 

A   NEW   WORK— PREPARING 

The  subject  of  Legal  .Medicine  is  one  of  great  importance,  especially  to  the 
general  practitioner,  for  it  is  to  him  that  calls  to  attend  cases  which  may  prove  to 
be  medicolegal  in  character  most  frequently  come.  The  medicolegal  tield  includes 
not  only  deaths  of  a  homicidal  nature,  but  also  suits  at  law — the  fatal  railway  acci- 
dent, machinery  casualties,  and  the  like,  to  which  the  neighboring  physician  may 
be  called,  and  later,  perhaps,  summoned  to  court.  It  is  evident,  therefore,  that 
even.'  practitioner  should  be  thoroughly  versed  in  all  branches  of  medicolegal 
science.  This  volume,  although  prepared  as  a  help  to  medical  students,  will  be 
found  no  less  valuable  and  instructive  to  practitioners.  The  author  has  not  only 
cited  illustrative  cases  from  the  standard  treatises  on  forensic  medicine,  but  these 
he  has  supplemented  with  details  from  his  own  exceptionally  full  experience — an 
experience  gained  during  his  service  as  Medical  Examiner  for  the  city  of  Boston 
for  the  past  twenty-six  years.  During  this  time  his  investigations  have  comprised 
nearly  seventy-seven  thousand  deaths  under  a  suspicion  of  violence.  It  will  be 
seen,  therefore,  that  the  work  is  authoritative,  and,  written  by  an  experienced 
teacher,  the  language  is  clear  and  concise. 

Jakob  and  Fisher V 

Nervous  System  and  its  Diseases 

Atlas  and   Epitome  of   the  Nervous    System    and  Its  Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Reviscel 
German  Edition.  Edited,  with  additions,  by  Edward  D.  Fisher,  M.  D., 
Professor  of  Diseases  of  the  Nervous  S}'stem,  University  and  Bellevue 
Hospital  [Medical  College,  New  York.  With  83  plates  and  copious  text. 
Cloth,  SSoO  net.     In  Saunders'  Hand-Atlas  Series. 

The  matter  is  divided  into  Anatomy,  Pathology,  and  Description  of  Diseases 
of  the  Nervous  System.  The  plates  illustrate  these  divisions  most  completely  ; 
especially  is  this  so  in  regard  to  pathology.  The  exact  site  and  character  of  the 
lesion  are  portrayed  in  such  a  way  that  they  cannot  fail  to  impress  themselves  on 
the  memon,'  of  the  reader. 

Philadelphia  Medical  Journal 

"  We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  scientific  fidelity  of  this  hand-atlas." 


DISEASES    OF   CHILDREN. 


American  Text- Book  of 
Diseases  of  Children 

American  Text=Book  of  Diseases  of  Children.  Edited  by  Louis 
Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hospital,  etc. ; 
assisted  by  Thompson  S.  Westcott,  M.  D.,  Attending  Physician  to  the 
Dispensary  for  Diseases  of  Children,  Hospital  of  the  University  of  Penn- 
sylvania. Handsome  octavo,  1244  pages,  profusely  illustrated.  Cloth, 
$7.00  net ;  Sheep  or  Half  Morocco,  ^8.00  net. 

SECOND   REVISED   EDITION 

To  keep  up  with  the  rapid  advances  in  the  field  of  pediatrics,  the  whole  sub- 
ject-matter embraced  in  the  first  edition  has  been  carefully  revised,  new  articles 
added,  some  original  papers  amended,  and  a  number  entirely  rewritten  and 
brought  up  to  date.  The  volume  has  thus  been  increased  in  size  by  a  very 
considerable  amount  of  fresh  material. 

British  Medical  Journal 

"  May  be  recommended  as  a  thoroughly  trustworthy  and  satisfactory  guide  to  the  subject 
of  the  diseases  of  children." 

Gould  and  Pyle*s 
Curiosities  of  Medicine 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.  D.,  and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare 
and  extraordinary  cases  and  of  the  most  striking  instances  of  abnormal- 
ity in  all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages,  295  engravings,  and  12  full-page  plates.  Pop- 
ular Edition  :  Cloth,  53-00  net ;  Sheep  or  Half  Morocco,  ^$4.00  net. 

As  a  complete  and  authoritative  Book  of  Reference,  this  work  will  be  of  value 
not  only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in 
general  scientific,  sociologic,  and  medicolegal  topics  ;  in  fact,  the  absence  of  any 
complete  work  upon  the  subject  makes  this  volume  one  of  the  most  important 
literary  innovations  of  the  day. 

New  York  Medical  Journal 

"We  would  gladly  exchange  a  multitude  of  the  relatively  useless  works  which  but  encumber 
all  branches  of  medicine,  for  one  so  comprehensive,  so  exhaustive,  so  able,  and  so  remarkable 
in  its  field  as  this." 


SAL'A'DEJiS'    BOOKS    ON 


Hofmann  and  Peterson's 
Leg(al  Medicine 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna, 
Edited  by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  De- 
partment, College  of  Physicians  and  Surgeons,  New  York..  With  120 
colored  figures  on  56  plates  and  193  half-tone  illustrations.  Cloth, 
33.50  net.     /;/  Saunders'  Hand-Atlas  Series. 

By  reason  of  the  wealth  of  illustrations  and  the  fidelity  of  the  colored  plates, 
the  book  supplements  all  the  text-books  on  the  subject.  Moreover,  it  furnishes  to 
ever}'  physician,  student,  and  lawyer  a  veritable  treasure-house  of  information. 

The  Practitioner,  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection  with 
this  department  of  medicine,  and  they  cannot  fail  to  be  useful  alike  to  the  medical  jurist  and  to 
the  student  of  forensic  medicine." 

Chapman's 
Medical  Jurisprudence 

Medical  Jurisprudence,  Insanity,  and  Toxicology.  By  Henry  C. 
Chapman,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical 
Jurisprudence  in  Jefferson  Medical  College,  Philadelphia.  Handsome 
i2mo  of  329  pages,  fully  illustrated.      Cloth,  ^1.75  net. 

JUST   ISSUED— THIRD   REVISED   EDITION.    ENLARGED 

This  work  is  based  on  the  author's  practical  experience  as  coroner's  physician 
of  the  city  of  Philadelphia  for  a  period  of  six  years.  Dr.  Chapman's  book, 
therefore,  is  of  unusual  value. 

This  third  edition  has  been  thoroughly  revised  and  greatly  enlarged,  so  as  to 
bring  it  absolutely  in  accord  with  the  very  latest  advances  in  this  important  branch 
of  medical  science.  There  is  no  doubt  it  will  meet  with  as  great  favor  as  the 
previous  editions. 

Journal  of  the  American  Medical  Association  —  In  Rcvieivivg  the  Second  Edition 

"  It  is  an  e.xcellent  manual  in  whicli  an  accurate  epitome  is  given  of  the  existing  knowledge 
on  the  suljject." 


NU/^S/NU.  1 1 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo  of  400  pages,  illustrated.     Buckram,  $1.75  net. 

This  volume  is  designed  for  the  obstetric  and  gynecologic  nurse.  Obstetric 
nursing  demands  some  knowledge  of  natural  pregnancy  and  of  the  signs  of  acci- 
dents and  diseases  which  may  occur  during  pregnancy.  It  also  requires  knowledge 
and  experience  in  the  care  of  the  patient  and  child.  Gynecologic  nursing  is  really 
a  branch  of  surgical  nursing,  and  as  such  requires  special  instruction  and  training. 
This  volume  presents  this  information  in  the  most  convenient  form. 

The  Lancet,  London 

"Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 

Watson's  Nursing 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.D.,  Edin.  Assistant 
House-Surgeon,  Sheffield  Royal  Hospital.  American  Edition,  under 
the  supervision  of  A.  A.  Stevens,  A.  M.,  M.  D.,  Professor  of  Pathology, 
Women's  Medical  College,  Philadelphia.  i2mo,  413  pages,  73  illustra- 
tions.    Cloth,  $1.50  net. 

This  work  aims  to  supply  in  one  volume  that  information  which  so  many  nurses 
at  the  present  time  are  trying  to  extract  from  various  medical  works,  and  to  present 
that  information  in  a  suitable  form.  Nurses  must  necessarily  acquire  a  certain 
amount  of  medical  knowledge,  and  the  author  of  this  book  has  aimed  judiciously 
to  cater  to  this  need  with  the  object  of  directing  the  nurses'  pursuit  of  medical 
information  in  proper  and  legitirnate  channels. 

Journal  of  the  American  Medical  Association 

"  The  intelligent  nurse  will  find  this  a  most  convenient  manual,  and  there  are  many  things 
in  it  that  the  physician  might  find  of  use.  In  recommending  text-books  to  nurses  it  could  be 
put  in  the  first  rank." 


S.-n^XDEJiS'    BOOKS    ON 


Golebiewski  and  Bailey's 
Accident  Diseases 


Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed, 

Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey, 
M.  D.,  Attending  Physician  to  the  Almshouse  and  Incurable  Hospitals, 
New  York.  With  71  colored  illustrations  on  40  plates,  143  text-illus- 
trations, and  549  pages  of  text.  Cloth,  ^4.00  net.  In  Saunders'  Hand- 
Atlas  Scries. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  accident 
injury  ;  the  functional  disability  caused  thereby  ;  the  medicolegal  questions  in- 
volved, and  the  amount  of  indemnity  justified  in  given  cases.  The  work  is 
indispensable  to  every  physician  who  sees  cases  of  injury  due  to  accidents,  to 
advanced  students,  to  surgeons,  and,  on  account  of  its  illustrations  and  statistical 
data,  it  is  none  the  less  useful  to  accident-insurance  organizations. 

The  Medical  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  grow- 
ing in  extent  all  the  time.     The  pictorial  part  of  the  book  is  very  satisfactory." 

Stoney*s 
Materia  Medica  for  Nurses 


Practical  Materia  Medica  for  Nurses,  with  an  Appendix  containing 
Poisons  and  their  Antidotes,  with  Poison-Emergencies  ;  Mineral  Waters  ; 
Weights  and  Measures  ;  Dose-List,  and  a  Glossary  of  the  Terms  used 
in  Materia  Medica  and  Therapeutics.  By  Emily  A.  M.  Stoney,  Super- 
intendent of  the  Training  School  for  Nurses  at  the  Carney  Hospital, 
South  Boston,  Mass.  Handsome  octavo  volume  of  306  pages.  Cloth, 
^1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of 
which  are  intended  to  render  it  more  practical  and  generally  useful.  The  consid- 
eration of  the  drugs  includes  their  names,  their  sources  and  composition,  their 
various  preparations,  physiologic  actions,  directions  for  handling  and  administer- 
ing, and  the  symptoms  and  treatment  of  poisoning. 

Journal  of  the  American  Medical  Association 

"  So  far  as  we  can  see,  it  contains  everything  that  a  nurse  ought  to  know  in  regard  to  drugs. 
As  a  reference-book  for  nurses  it  will  without  question  be  very  useful." 


CI  III.})  REX  AND    IIYCIF.XE. 


Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Penn. ;  Physician  to  the 
Children's  Hospital,  Phila.    i2mo,  436  pp.   Illustrated.    Cloth,  $1.50  net. 

JUST    ISSUED— THIRD    EDITION,  THOROUGHLY   REVISED 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  in  the  hope  that  the  volume 
mav  be  of  service  not  only  to  mothers  and  nurses,  but  also  to  students  and  practi- 
tioners whose  opportunities  for  observing  children  have  been  limited. 

New  York  Medical  Journal 

"  We  are  confident  if  this  little  work  could  find  its  way  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lessened  by  at  least  fifty  per  cent." 

Crothers'  Morphinism 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs  ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  ByT.  D.  Crothers,  M.  D.,  Superintendent 
of  Walnut  Lodge  Hospital,  Hartford,  Conn.  Handsome  i2mo  of  351 
pages.     Cloth,  ^2.00  net. 

The  Lancet,  London 

"An  excellent  account  of  the  various  causes,  symptoms,  and  stages  of  morphinism,  the 
discussion  being  throughout  illuminated  by  an  abundance  of  facts  of  clinical,  psychological,  and 
social  interest." 

Abbott's  Transmissible  Diseases 

The  Hygiene  of  Transmissible  Diseases :  Their  Causation,  Modes 
of  Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  $2.50  net. 

SECOND   REVISED    EDITION 

During  the  interval  that  has  elapsed  since  the  appearance  of  the  first  edition 
investigations  upon  the  modes  of  dissemination  of  certain  of  the  specific  infections 
have  been  very  active.  The  sections  on  Malaria,  Yellow  Fever,  Plague,  Filariasis, 
Dysentery,  and  Tuberculosis  have  been  both  revised  and  enlarged. 

The  Lancet,  London 

"  We  heartily  commend  the  book  as  a  concise  and  trustworthy  guide  in  the  subject  with 
which  it  deals,  and  we  sincerely  congratulate  Professor  Abbott." 


1 4  SAr.XDEA'S'    BOOKS    ON 


Stoney*s  Nursing 


Practical  Points  in  Nursing :  for  Nurses  in  Private  Practice.  By 
Emily  A.  M.  Stoney,  Superintendent  of  the  Training  School  for  Nurses 
at  the  Carney  Hospital,  South  Boston,  Mass.  466  pages,  fully  illus- 
trated.    Cloth,  $1.75  net. 

JUST  ISSUED  — THIRD  EDITION.  THOROUGHLY  REVISED 

In  this  volume  the  author  explains  the  entire  range  oi  private  nursing  as  dis- 
tinguished from  hospital  nursing,  and  the  nurse  is  instructed  how  best  to  meet  the 
various  emergencies- of  medical  and  surgical  cases  when  distant  from  medical  or 
surgical  aid  or  when  thrown  on  her  own  resources.  An  especially  valuable  feature 
will  be  found  in  the  directions  how  to  improvise  everything  ordinarily  needed  in  the 
sick-room. 

The  Lancet,  London 

"A  very  complete  exposition  of  practical  nursing  in  its  various  branches,  including  obstetric 
and  gynecologic  nursing.     The  instructions  given  are  full  of  useful  detail." 


Stoney *s  Bacteriology  anb 
Surgical  Technic  for  Nurses 


Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M. 
Stoney,  Superintendent  of  the  Training  School  for  Nurses  at  the 
Carney  Hospital,  South  Boston,  Mass.  i2mo,  200  pages,  profusely 
illustrated.     Cloth,  ^1.25   net. 

The  work  is  intended  as  a  modern  text-book  on  Surgical  Nursing  in  both  hos- 
pital and  private  practice.  The  first  part  of  the  book  is  devoted  to  Bacteriology 
and  Antiseptics  ;  the  second  part  to  Surgical  Technic,  Signs  of  Death,  and 
Autopsies.  The  matter  ins  the  book  is  presented  in  a  practical  form,  and  will 
prove  of  value  t*-    .^  nurses  who  are  called  upon  to  attend  surgical  cases. 

Trained  Nurse  and  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  «o  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value  both  durijig 
their  hospital  course  and  in  private  practice." 


NERVOUS  AND   MENTAL   DISEASES. 


American  Pocket  Dictionary  Fourth  Edition.  Revised 

American  Pocket  Medical  Dictionary.  Edited  by  \\ .  A.  New- 
man Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the 
University  of  Pennsylvania.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dean 
of  the  Jefferson  Medical  College,  Philadelphia. 

Warwick  and  Tunstall's  First  Aid 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.  A., 
M.  B.  Cantab.,  Associate  of  King's  College,  London  ;  and  A.  C.  Tun- 
stall,  M.  D.,  F.  R.  C.  S.  Edin.,  Surgeon-Captain  Commanding  the  East 
London  Volunteer  Brigade  Bearer  Company.  i6mo  of  232  pages  and 
nearly  200  illustrations.     Cloth,  $1.00  net. 

■'  Contains  a  great  deal  of  valuable  information  well  and  tersely  expressed.  It  will 
prove  especially  useful  to  the  volunteer  first  aid  and  hospital  corps  men  of  the  National 
Guard." — Journal  American  Medical  Association. 

Saunders*  American  Year-Book 

American  Year-Book  of  Medicine  and  Surgery.  A  Yearly  Digest 
of  Scientific  Progress  and  Authoritative  Opinion  on  all  Branches  of 
Medicine  and  Surgery,  drawn  from  journals,  monographs,  and  text-books 
of  the  leading  American  and  foreign  authors  and  investigators.  Arranged, 
with  critical  editorial  comments,  by  eminent  American  specialists,  under 
the  editorial  charge  of  George  M.  Gould,  A.  M.,  M.  D.  In  two 
volumes:  Vol.  I. — General  Medicine,  octavo,  715  pages,  illustrated; 
Vol.  II.  —  General  Surgery,  octavo,  684  pages,  illustrated.  Per  volume  : 
Cloth,  $3.00  net;  Sheep  or  Half  Morocco,  S3. 75  net.  Sold  by  Sub- 
scription. 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted 
to  experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical 
commentaries  and  expositions  .  .  .  proceeding  from  writers  fully  qualified  to  perform 
these  tasks." — The  Lancet,  London. 

f««  mr  r>*  IV  •!  Third  £dition> 

Shaw  on  Nervous  Diseases  and  Insanity  Revised 

Essentials  of  Nervous  Diseases  and  Insanity  :  their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the  late 
John  C.  Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  ISIind  and 
Nervous  System,  Long  Island  College  Hospital,  Ne^y  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  $1.00  net.  Jn  Saunders'  Question- Com- 
pend  Series. 

"Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted.  ' 
—Boston  Medical  and  Surgical  Journal. 

Chapin*s  Insanity 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  Honorary 
Member  of  the  Medico-Psychological  Society  of  Great  Britain,  of  the 
Society  of  jMental  Medicine  of  Belgium,  etc.  i2mo,  234  pages,  illus- 
trated.    Cloth,  $1.25  net. 

"  It  is  not  a  made  book,  but  a  genuine  condensed  thesis,  which  has  all  the  value  of  ripe 
opinion  and  all  the  charm  of  a  vigorous  and  natural  style." — Philadelphia  Medical  Journal. 


s.ir.y/>/:A's-  />'ooa's  (W  c/f/i.D/^KX. 


Griffith's  Weight  Chart 

Infants'  Weight  Chaki'.  Designed  by  J.  P.  Crozer  Griffith, 
M.  n.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of 
Pennsylvania  ;  I'hysician  to  the  Children's  Hospital,  to  the  Methodist 
Episcopal  Hospital,  and  to  St.  Agnes'  Hospital,  Philadelphia.  25  charts 
in  each  pad.     Price  per  pad,  50  cents  net. 

I'rinti'tl  on  each  chart  is  a  curve  representing;  the  average  weight  of  a  healthy  infant. 
so  that  any  deviation  from  the  normal  can  readily  be  detected. 

Powell's    Diseases    of    Children  Third  Edition.  Revised 

ESSENTIAL.S  OF  THE  DISEASES  OF  CHILDREN.      By  WiLLlAM  M.  POWELL, 

M.  D.,  author  of  "  Saunders'  Pocket  Medical  Formulary,"  etc.  Revised 
by  Alfred  Hand,  Jr.,  A.  B.,  M.  I).,  Dispensary  Physician  and  Pathol- 
ogist to  the  Children's  Hospital,  Philadelphia.  lamo  volume  of  259 
pages.     Cloth,  g 1. 00  net.     ///  Saunders^  Questio7j-Compend  Series. 

"  One  of  the  best  books  of  this  excellent  Question  Series,  and  one  which  will  prove 
very  popular." — The  Medical  World,  Philadelphia. 

Starr's  Diets  for  Infants  and  Children 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By 
Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hospital, 
Philadelphia;  editor  of  "American  Text-Book  of  the  Diseases  of  Chil- 
dren." 230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  Morocco,  §1.25  net. 

"  The  diets  are  various  and  well  selected,  and  are  adapted  to  children  of  all  ages.  At 
the  end  of  the  book  are  a  few  simple  recipes  which  can  be  detached  and  given  to  the 
nurse." — British  Medical  Journal. 

Grafstrom's  Mechano-Therapy 

A  Text-Book  of  Mechano-therapv  (Massage  and  Medical  Gymnas- 
tics). By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician, 
City  Hospital,  Blackwell's  Island,  New  York.  i2mo,  139  pages,  illus- 
trated.    Cloth,  Sioo  net. 

"Certainly  fulfills  its  mission  in  rendering  comprehensible  the  subjects  of  mas.sage  and 
medical  gymnastics." — New  York  Medical  Journal. 

Meigs'  Feeding  in  Infancy 

li.KDiN(;  IN  ICaki.v  Infancv.  By  Arthur  v.  Meigs,  M.  D.,  Physician 
to  the  Pennsylvania  Hospital,  Philadelphia.  Bound  in  limp  Cloth,  flush 
edges,  25  cents  net. 


<-^/^/ 


/v^a/ 


O  7^     /^/  <2?^o2^  <f^^7  . 


X  i?:- 


